Provider Demographics
NPI:1851173678
Name:SHANNON, JASMINE S
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:S
Last Name:SHANNON
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 1:502 GOLDEN EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-5502
Mailing Address - Country:US
Mailing Address - Phone:601-291-2902
Mailing Address - Fax:
Practice Address - Street 1:502 GOLDEN EAGLE DR
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-5502
Practice Address - Country:US
Practice Address - Phone:601-291-2902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)