Provider Demographics
NPI:1780219139
Name:JONES, SHANNON RENIQUE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENIQUE
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18237 SWISS CIR APT 1
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-5853
Mailing Address - Country:US
Mailing Address - Phone:336-471-7399
Mailing Address - Fax:
Practice Address - Street 1:18237 SWISS CIR APT 1
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-5853
Practice Address - Country:US
Practice Address - Phone:336-471-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP10150101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty