Provider Demographics
NPI:1104356856
Name:SMITH, SHANNON JAVON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JAVON
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:SMITH
Other - Last Name:ASHLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1785 HIGHWAY 162
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-4528
Mailing Address - Country:US
Mailing Address - Phone:318-272-5868
Mailing Address - Fax:
Practice Address - Street 1:1717 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4139
Practice Address - Country:US
Practice Address - Phone:318-226-9944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health