Provider Demographics
NPI:1841821113
Name:JACOBS, SHANNON REBECCA (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:REBECCA
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:REBECCA
Other - Last Name:PULLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-S
Mailing Address - Street 1:7137 N BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-4822
Mailing Address - Country:US
Mailing Address - Phone:816-797-2111
Mailing Address - Fax:
Practice Address - Street 1:4906 N OAK TRFY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-4617
Practice Address - Country:US
Practice Address - Phone:816-797-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA14832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program