Provider Demographics
NPI:1053991091
Name:JASPER, SHAN
Entity type:Individual
Prefix:
First Name:SHAN
Middle Name:
Last Name:JASPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 E BLACK DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3718
Mailing Address - Country:US
Mailing Address - Phone:480-228-2175
Mailing Address - Fax:
Practice Address - Street 1:1355 E BLACK DIAMOND DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3718
Practice Address - Country:US
Practice Address - Phone:480-228-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy