Provider Demographics
NPI:1225139959
Name:JERNIGAN, SHANON REYNOLDS (MD)
Entity Type:Individual
Prefix:
First Name:SHANON
Middle Name:REYNOLDS
Last Name:JERNIGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W. HICKORY ST.
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2913
Mailing Address - Country:US
Mailing Address - Phone:256-401-4000
Mailing Address - Fax:256-401-4603
Practice Address - Street 1:33733 US HIGHWAY 280
Practice Address - Street 2:
Practice Address - City:CHILDERSBURG
Practice Address - State:AL
Practice Address - Zip Code:35044-3017
Practice Address - Country:US
Practice Address - Phone:256-378-3301
Practice Address - Fax:256-378-3026
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51549289OtherBCBS
AL103337Medicaid
ALMD.27306OtherLICENSE
ALMD.27306OtherLICENSE
AL51549289OtherBCBS