Provider Demographics
NPI:1043669179
Name:SHAFFER, JESSICA (LISW-S)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 N 3RD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-5550
Mailing Address - Country:US
Mailing Address - Phone:740-349-7511
Mailing Address - Fax:740-522-4263
Practice Address - Street 1:15 N 3RD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5550
Practice Address - Country:US
Practice Address - Phone:740-349-7511
Practice Address - Fax:740-522-4263
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
OHI0900294104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2892946Medicaid