Basic Information
| Provider Information | |||||||||
| NPI: | 1134313265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAFER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | GORDON | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572066 | ||||||||
| FaxNumber: | 4238572070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2033 MEADOWVIEW LN | ||||||||
| Address2: | STE 200 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376607569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572260 | ||||||||
| FaxNumber: | 4238572261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2007 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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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 | 207Q00000X | DO2150 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2009-01172 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1521048 | 05 | TN | MEDICAID |