Provider Demographics
NPI:1053377606
Name:SHAMBAUGH, JENNIFER (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHAMBAUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2700 LAFAYETTE ST
Mailing Address - Street 2:STE B-10
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-1100
Mailing Address - Country:US
Mailing Address - Phone:260-744-7004
Mailing Address - Fax:
Practice Address - Street 1:2700 LAFAYETTE ST
Practice Address - Street 2:STE B-10
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1100
Practice Address - Country:US
Practice Address - Phone:260-744-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002009A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q54720Medicare UPIN
IN150640OMedicare PIN