Provider Demographics
NPI:1710543939
Name:JETTON, SHANNON MICHELLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:JETTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 75TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2525
Mailing Address - Country:US
Mailing Address - Phone:806-712-1096
Mailing Address - Fax:806-771-2093
Practice Address - Street 1:1305 WONDER WORLD DR STE 101
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7502
Practice Address - Country:US
Practice Address - Phone:512-353-6430
Practice Address - Fax:855-618-2314
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily