Provider Demographics
NPI:1073649919
Name:HENDRICKSON, SHANNON JANE (PMHCNS,BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JANE
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:PMHCNS,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MYSTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4632
Mailing Address - Country:US
Mailing Address - Phone:781-396-1199
Mailing Address - Fax:781-396-1439
Practice Address - Street 1:151 MYSTIC AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4632
Practice Address - Country:US
Practice Address - Phone:781-396-1199
Practice Address - Fax:781-396-1439
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110897101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP19166Medicare UPIN
MANS0425Medicare PIN