Provider Demographics
NPI:1922356682
Name:SHAUGHNESSY, JENNA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:SHAUGHNESSY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:TITLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 LAURENCE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2979
Mailing Address - Country:US
Mailing Address - Phone:517-751-4777
Mailing Address - Fax:517-782-4717
Practice Address - Street 1:1001 LAURENCE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2979
Practice Address - Country:US
Practice Address - Phone:517-751-4777
Practice Address - Fax:517-782-4717
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2939225100000X
MI3613166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist