Provider Demographics
NPI:1982995643
Name:ROBERTSON, SHANNON (DC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 NW MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3295
Mailing Address - Country:US
Mailing Address - Phone:503-719-5335
Mailing Address - Fax:503-719-5334
Practice Address - Street 1:1413 CHARNELTON ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3906
Practice Address - Country:US
Practice Address - Phone:541-762-1755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor