Basic Information
| Provider Information | |||||||||
| NPI: | 1528343894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAMESON | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T., D.P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1190 E MISSOURI AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023930520 | ||||||||
| FaxNumber: | 6023930523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 E MISSOURI AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023930520 | ||||||||
| FaxNumber: | 6023930523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2011 | ||||||||
| LastUpdateDate: | 10/18/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251N0400X | 9521 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
No ID Information.