Provider Demographics
NPI:1023204534
Name:SHACKELFORD, JASON MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MICHAEL
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:500 OLD YORK RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2852
Mailing Address - Country:US
Mailing Address - Phone:215-886-0174
Mailing Address - Fax:215-886-9217
Practice Address - Street 1:500 OLD YORK RD
Practice Address - Street 2:SUITE 203
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2852
Practice Address - Country:US
Practice Address - Phone:215-886-0174
Practice Address - Fax:215-886-9217
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD436110207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA162012Medicare PIN