Provider Demographics
NPI:1972935641
Name:SHANNON, JASON J (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:J
Last Name:SHANNON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1012 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4226
Mailing Address - Country:US
Mailing Address - Phone:769-524-4686
Mailing Address - Fax:601-944-9780
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-968-1000
Practice Address - Fax:601-944-9780
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872238367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered