Provider Demographics
NPI:1275053969
Name:SHANNON, JILLIAN LEIGH
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEIGH
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-2511
Mailing Address - Country:US
Mailing Address - Phone:541-720-0804
Mailing Address - Fax:
Practice Address - Street 1:1175 CARONDELET DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-3300
Practice Address - Country:US
Practice Address - Phone:509-943-9104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health