Provider Demographics
NPI:1417281064
Name:JACKSON, SHANNON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 NORTH MAIN STREET
Mailing Address - Street 2:ECHN ADULT AMBULATORY SERVICES
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4188
Mailing Address - Country:US
Mailing Address - Phone:860-647-6832
Mailing Address - Fax:860-647-6831
Practice Address - Street 1:150 NORTH MAIN ST
Practice Address - Street 2:ECHN HEALTH SERVICES
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4188
Practice Address - Country:US
Practice Address - Phone:860-647-6832
Practice Address - Fax:860-647-6831
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00297103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical