Basic Information
| Provider Information | |||||||||
| NPI: | 1225139959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JERNIGAN | ||||||||
| FirstName: | SHANON | ||||||||
| MiddleName: | REYNOLDS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 W. HICKORY ST. | ||||||||
| Address2: | |||||||||
| City: | SYLACAUGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351502913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564014000 | ||||||||
| FaxNumber: | 2564014603 | ||||||||
| Practice Location | |||||||||
| Address1: | 33733 US HIGHWAY 280 | ||||||||
| Address2: | |||||||||
| City: | CHILDERSBURG | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350443017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563783301 | ||||||||
| FaxNumber: | 2563783026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27306 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 51549289 | 01 | AL | BCBS | OTHER | 103337 | 05 | AL | MEDICAID | MD.27306 | 01 | AL | LICENSE | OTHER |