Provider Demographics
NPI:1255867420
Name:JENKINS, SHANNON (CMT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8357 CARTERS MILL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231
Mailing Address - Country:US
Mailing Address - Phone:804-591-5012
Mailing Address - Fax:
Practice Address - Street 1:1307 JAMESTOWN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-229-4161
Practice Address - Fax:757-564-0581
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019013639225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA350504530010Medicaid