Provider Demographics
NPI:1053829507
Name:SHAFFER, JESSICA LEE (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N STATE ROAD 135 STE 106
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1351
Mailing Address - Country:US
Mailing Address - Phone:317-883-8791
Mailing Address - Fax:
Practice Address - Street 1:107 N STATE ROAD 135 STE 106
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1351
Practice Address - Country:US
Practice Address - Phone:317-884-8791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28185492A163WE0003X
IN71008066A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency