Provider Demographics
NPI:1780164954
Name:NOWELL, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:NOWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 POINSETTIA ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32233-4020
Mailing Address - Country:US
Mailing Address - Phone:904-910-7393
Mailing Address - Fax:
Practice Address - Street 1:294 POINSETTIA ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32233-4020
Practice Address - Country:US
Practice Address - Phone:904-910-7393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-19-37606103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician