Healthcare Provider Details

I. General information

NPI: 1386564557
Provider Name (Legal Business Name): SHANNON JACOBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON COULTAS

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 MAIN ST
VERGENNES VT
05491-1155
US

IV. Provider business mailing address

75 W MAIN ST
VERGENNES VT
05491-1064
US

V. Phone/Fax

Practice location:
  • Phone: 206-226-6381
  • Fax:
Mailing address:
  • Phone: 206-226-6381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: