Provider Demographics
NPI:1942559067
Name:DR. JOHN J SHANNON, PA
Entity Type:Organization
Organization Name:DR. JOHN J SHANNON, PA
Other - Org Name:COUNSELING SERVICE OF CENTRAL JERSEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD CLINICAL PSYCH
Authorized Official - Phone:732-566-9222
Mailing Address - Street 1:TWO NAWATAM WAY
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3018
Mailing Address - Country:US
Mailing Address - Phone:732-566-9222
Mailing Address - Fax:732-566-9298
Practice Address - Street 1:TWO NAWATAM WAY
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-3018
Practice Address - Country:US
Practice Address - Phone:732-566-9222
Practice Address - Fax:732-566-9298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S1000045200103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3155706Medicaid
NJ3155706Medicaid