MEDICARE: PATRICIA JEAN SHANNON PHD, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	4075	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053419796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA JEAN SHANNON PHD, LP

Provider Business Mailing Address
First Line	:	3108 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2619
Country	:	US
Telephone Number	:	612-825-4407
Fax Number	:	612-825-0768

Provider Business Practice Location Address
First Line	:	3133 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2620
Country	:	US
Telephone Number	:	612-834-7780
Fax Number	:	612-624-3744

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	09/29/2015

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