Provider Demographics
NPI:1598001216
Name:SHANNON, JILLIAN (PT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:BLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:592 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-4006
Practice Address - Country:US
Practice Address - Phone:781-828-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035711225100000X
MA20321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist