Healthcare Provider Details

I. General information

NPI: 1265786396
Provider Name (Legal Business Name): SHANNON NICHOLE MODJESKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON NICHOLE MARCUS

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 W 10TH ST
MEDFORD OR
97501-3016
US

IV. Provider business mailing address

816 W 10TH ST
MEDFORD OR
97501-3016
US

V. Phone/Fax

Practice location:
  • Phone: 541-734-5437
  • Fax: 541-734-2425
Mailing address:
  • Phone: 541-734-5437
  • Fax: 541-734-2425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC14009
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: