Provider Demographics
NPI:1013982768
Name:SHANNON, JENNIFER JOY (MFC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JOY
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4104
Mailing Address - Country:US
Mailing Address - Phone:707-703-5199
Mailing Address - Fax:
Practice Address - Street 1:613 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4104
Practice Address - Country:US
Practice Address - Phone:707-703-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 30265101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health