Provider Demographics
NPI:1841751112
Name:JAROSIK, SHANNON RENEE (COTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:JAROSIK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BARTELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5285
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5285
Mailing Address - Country:US
Mailing Address - Phone:308-675-1853
Mailing Address - Fax:308-210-4121
Practice Address - Street 1:1924 W A ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5650
Practice Address - Country:US
Practice Address - Phone:402-461-7578
Practice Address - Fax:402-461-7509
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE973224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty