Provider Demographics
NPI:1891092722
Name:JIMERSON, SHANNA A (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:A
Last Name:JIMERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:SHANNA
Other - Middle Name:A
Other - Last Name:PAINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 306393
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6393
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:
Practice Address - Street 1:3451 GOODMAN RD E STE 108
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9305
Practice Address - Country:US
Practice Address - Phone:662-890-6953
Practice Address - Fax:662-890-6954
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3331225100000X
ALPTH6346225100000X
MSPT6112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186547721Medicaid
AR5V981F804Medicare PIN
J229Medicare UPIN