Provider Demographics
NPI:1225545650
Name:DOUGLAS, SHANNON L (LLMSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2121
Mailing Address - Country:US
Mailing Address - Phone:517-787-7920
Mailing Address - Fax:517-787-2440
Practice Address - Street 1:330 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2121
Practice Address - Country:US
Practice Address - Phone:517-787-7920
Practice Address - Fax:517-787-2440
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011019521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical