Healthcare Provider Details

I. General information

NPI: 1265142327
Provider Name (Legal Business Name): SHANNON HURST LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 WOODLAWN AVE
DYERSBURG TN
38024-1300
US

IV. Provider business mailing address

257 BANCORP SOUTH PKWY
JACKSON TN
38305-7582
US

V. Phone/Fax

Practice location:
  • Phone: 731-285-1393
  • Fax: 731-286-1423
Mailing address:
  • Phone: 731-660-8781
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8276
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: