Provider Demographics
NPI:1144858200
Name:SHANNON, JESSICA LOUISE (RBT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18288 N US HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-4400
Mailing Address - Country:US
Mailing Address - Phone:813-527-9638
Mailing Address - Fax:
Practice Address - Street 1:1813 LAKE CHAPMAN DR UNIT 201
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4158
Practice Address - Country:US
Practice Address - Phone:901-444-1629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician