Individual
JAMIE SHANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
404 HUNTER ST, ESPANOLA, NM 87532-2655
(505) 753-4123
(505) 753-6947
Mailing address
404 HUNTER ST, ESPANOLA, NM 87532-2655
(505) 753-4123
(505) 753-6947
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
E7436
—
NM
Enumeration date
06/24/2014
Last updated
06/24/2014
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