Provider Demographics
NPI:1548595234
Name:JERNIGAN, SHANNON LEIGH (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEIGH
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 SOUTHERN JUNCTION BLVD
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2214
Mailing Address - Country:US
Mailing Address - Phone:912-348-1910
Mailing Address - Fax:
Practice Address - Street 1:125 SOUTHERN JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2214
Practice Address - Country:US
Practice Address - Phone:912-348-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7335225X00000X
GA006678225X00000X
CO0003298225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist