Basic Information
| Provider Information | |||||||||
| NPI: | 1003948928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHATTUCK | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4772 KATELLA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907202681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624308700 | ||||||||
| FaxNumber: | 5624308760 | ||||||||
| Practice Location | |||||||||
| Address1: | 4772 KATELLA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907202681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624308700 | ||||||||
| FaxNumber: | 5624308760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225000000X | AA358119 | CA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter | 225X00000X | AA358119 | CA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XE1200X | AA358119 | CA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Ergonomics | 225XH1200X | AA358119 | CA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 5481969 | 01 | CA | FIRST HEALTH ID | OTHER | OT0048180 | 01 | CA | BLUE SHIELD PIN | OTHER |