Provider Demographics
NPI:1942303896
Name:SHANAHAN, JESSICA IX
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHANAHAN
Suffix:IX
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:PO BOX 187
Mailing Address - Street 2:ROUTE 9 GRAND UNION PLAZA
Mailing Address - City:VALATIE
Mailing Address - State:NY
Mailing Address - Zip Code:12184-0187
Mailing Address - Country:US
Mailing Address - Phone:518-758-7616
Mailing Address - Fax:
Practice Address - Street 1:10B MADISON AVENUE EXT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-7314
Practice Address - Country:US
Practice Address - Phone:518-867-3061
Practice Address - Fax:518-867-3066
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02651930Medicaid
NYQ18Q21Medicare ID - Type Unspecified
NYQ38501Medicare UPIN