Provider Demographics
NPI:1053829507
Name:SHAFFER, JESSICA LEE (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 WESTERN BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9217
Mailing Address - Country:US
Mailing Address - Phone:317-708-0798
Mailing Address - Fax:
Practice Address - Street 1:313 WESTERN BLVD STE F
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9217
Practice Address - Country:US
Practice Address - Phone:317-708-0798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28185492A163WE0003X
IN71008066A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency