=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073897500
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON LEIGH JENNINGS LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2011
-----------------------------------------------------
Last Update Date | 10/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 EXECUTIVE CT
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-1970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-923-9214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 631 OLIVER LN
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-4484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-879-4397
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 65191
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------