Provider Demographics
NPI:1003817701
Name:SHODA, JAYNE S (MSN, FNP-C)
Entity Type:Individual
Prefix:MS
First Name:JAYNE
Middle Name:S
Last Name:SHODA
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W. EMMA AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-964-0701
Mailing Address - Fax:818-365-4031
Practice Address - Street 1:1600 SAN FERNANDO RD.
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340
Practice Address - Country:US
Practice Address - Phone:818-365-8086
Practice Address - Fax:818-898-4826
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP956A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q04196Medicare UPIN