Basic Information
| Provider Information | |||||||||
| NPI: | 1043669179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAFFER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 N 3RD ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403497511 | ||||||||
| FaxNumber: | 7405224263 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 N 3RD ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403497511 | ||||||||
| FaxNumber: | 7405224263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2016 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | I0900294 | OH | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 2892946 | 05 | OH | MEDICAID |