Active NPI
Shannon Nichole Modjeski
- Counselor
- Medford, OR
National Provider Identifier
1265786396
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Counselor
- License
- LAC14009
- Practice address
- 816 W 10TH St
Medford, OR 97501-3016 - Phone
- (541) 734-5437
- Fax
- (541) 734-2425
- NPI assigned
- Oct 26, 2012
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counselor | 101Y00000X | LAC14009 | AZ | Primary |
Addresses
Primary practice location
816 W 10TH St
Medford, OR 97501-3016
Mailing address
816 W 10TH St
Medford, OR 97501-3016
Phone (541) 734-5437
Other names 1
- Shannon Nichole Marcus
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jan 22, 2026 through Jan 22, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LAC14009 | AZ | MD | Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1351209600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1464739200000",
"number": "1265786396",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "816 W 10TH ST",
"city": "MEDFORD",
"state": "OR",
"postal_code": "975013016",
"telephone_number": "541-734-5437",
"fax_number": "541-734-2425"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "816 W 10TH ST",
"city": "MEDFORD",
"state": "OR",
"postal_code": "975013016",
"telephone_number": "541-734-5437",
"fax_number": "541-734-2425"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MODJESKI",
"first_name": "SHANNON",
"middle_name": "NICHOLE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2012-10-26",
"last_updated": "2016-06-01",
"status": "A"
},
"taxonomies": [
{
"code": "101Y00000X",
"taxonomy_group": "",
"desc": "Counselor",
"state": "AZ",
"license": "LAC14009",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "SHANNON",
"last_name": "MARCUS",
"middle_name": "NICHOLE",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Medford, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 1, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.