Provider Demographics
NPI:1265786396
Name:MODJESKI, SHANNON NICHOLE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICHOLE
Last Name:MODJESKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:NICHOLE
Other - Last Name:MARCUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:816 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3016
Mailing Address - Country:US
Mailing Address - Phone:541-734-5437
Mailing Address - Fax:541-734-2425
Practice Address - Street 1:816 W 10TH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3016
Practice Address - Country:US
Practice Address - Phone:541-734-5437
Practice Address - Fax:541-734-2425
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC14009101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor