Basic Information
| Provider Information | |||||||||
| NPI: | 1003817701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHODA | ||||||||
| FirstName: | JAYNE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 W. EMMA AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089640701 | ||||||||
| FaxNumber: | 8183654031 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SAN FERNANDO RD. | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183658086 | ||||||||
| FaxNumber: | 8188984826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 12/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP956A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.