Provider Demographics
NPI:1679745921
Name:COFFEY, SHANNON DAWN (LMHC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DAWN
Last Name:COFFEY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:DAWN
Other - Last Name:ISHEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:PO BOX 19249
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9249
Mailing Address - Country:US
Mailing Address - Phone:904-743-1883
Mailing Address - Fax:904-743-5109
Practice Address - Street 1:11820 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6670
Practice Address - Country:US
Practice Address - Phone:904-642-9100
Practice Address - Fax:904-642-9108
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4581101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762023300Medicaid