Provider Demographics
NPI:1083134688
Name:SHANNON, JOSEPH (DPT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10121 SE SUNNYSIDE RD STE 208
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5750
Mailing Address - Country:US
Mailing Address - Phone:503-794-0103
Mailing Address - Fax:
Practice Address - Street 1:15390 NW CORNELL RD STE 230
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5627
Practice Address - Country:US
Practice Address - Phone:971-245-6663
Practice Address - Fax:971-245-6664
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist