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General NPI Number Information
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NPI Number | 1528050812
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Entity Type | Individual
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Provider Name | JENNIFER LOUISE SHANNON MSW, LICSW
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Gender | Female
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Dates
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Enumeration Date | 08/22/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 30 CONWELL ST #1
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City | PROVINCETOWN
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State | MA
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Zip | 02657-1548
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Country | US
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Telephone | 508-487-1192
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Fax | 508-487-5813
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Provider Business Mailing Address
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Address Line | PO BOX 2014
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City | TRURO
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State | MA
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Zip | 02666-2014
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Country | US
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Telephone | 508-487-1192
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Fax | 508-487-5813
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 107036
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License Number State | MA
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