Provider Demographics
NPI:1073838322
Name:SHAFFER, JENNY LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNNE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:LYNNE
Other - Last Name:BUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11475 OLDE CABIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7129
Mailing Address - Country:US
Mailing Address - Phone:314-991-8200
Mailing Address - Fax:314-991-8206
Practice Address - Street 1:10010 KENNERLY ROAD
Practice Address - Street 2:ATTN CANCER CARE CENTER
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-1688
Practice Address - Fax:314-525-1689
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170141592085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1073838322Medicaid