Provider Demographics
NPI:1376521427
Name:JOHNSON, SHANNON JILL (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:JILL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-4532
Mailing Address - Country:US
Mailing Address - Phone:360-293-5831
Mailing Address - Fax:
Practice Address - Street 1:PSC 475 BOX 1
Practice Address - Street 2:
Practice Address - City:YOKOSUKA
Practice Address - State:JAPAN
Practice Address - Zip Code:FPO AP 96350
Practice Address - Country:JP
Practice Address - Phone:046-816-5247
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL001186103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical