Basic Information
| Provider Information | |||||||||
| NPI: | 1548559099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHACKLEFORD | ||||||||
| FirstName: | JARREL | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TUSTIN | ||||||||
| OtherFirstName: | JARREL | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 936857 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311936857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106628765 | ||||||||
| FaxNumber: | 9103629123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1814 NEW HANOVER MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284035350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106628765 | ||||||||
| FaxNumber: | 9103629123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-12100 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA00580 | RI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1548559099 | 01 | RI | NEIGHBORHOOD HEALTH PLAN | OTHER | 4744074 | 01 | RI | AETNA | OTHER |