Basic Information
| Provider Information | |||||||||
| NPI: | 1801170220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAFFER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 ROBB ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032787418 | ||||||||
| FaxNumber: | 3032239315 | ||||||||
| Practice Location | |||||||||
| Address1: | 6121 W 60TH AVE | ||||||||
| Address2: | |||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800035603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034204550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2011 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 019151 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 13862744 | 01 | CO | CAQH | OTHER | PSY.0004404 | 01 | CO | PROFESSIONAL LICENSE | OTHER |