Provider Demographics
NPI:1578998191
Name:ROSS, SHANNAN JO (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNAN
Middle Name:JO
Last Name:ROSS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28118 19TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:WA
Mailing Address - Zip Code:98580-9506
Mailing Address - Country:US
Mailing Address - Phone:253-254-2012
Mailing Address - Fax:
Practice Address - Street 1:4301 S PINE ST STE 301
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7206
Practice Address - Country:US
Practice Address - Phone:253-476-6500
Practice Address - Fax:253-476-6547
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60268179104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker