Basic Information
Provider Information | |||||||||
NPI: | 1649266727 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCHAAL | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 802 GREEN VALLEY RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274087041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3363700277 | ||||||||
FaxNumber: | 3363339757 | ||||||||
Practice Location | |||||||||
Address1: | 802 GREEN VALLEY RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274087041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3363700277 | ||||||||
FaxNumber: | 3363339757 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2005 | ||||||||
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 | 174400000X | 30123 | NC | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 49002 | 01 | NC | MEDCOST | OTHER | 1159 | 01 | NC | PARTNERS HMO | OTHER | 353113 | 01 | NC | ONE HEALTH | OTHER | 74776 | 01 | NC | BCBS | OTHER | 890166B | 05 | NC |   | MEDICAID | 0700817 | 01 | NC | UNITED HEALTH CARE | OTHER |