Provider Demographics
NPI:1114160470
Name:JAY-PETERSON, SHANTEL (ITDS)
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:
Last Name:JAY-PETERSON
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 LEWIS TURNER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1316
Mailing Address - Country:US
Mailing Address - Phone:850-862-3728
Mailing Address - Fax:850-862-6270
Practice Address - Street 1:2104 LEWIS TURNER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1316
Practice Address - Country:US
Practice Address - Phone:850-862-3728
Practice Address - Fax:850-862-6270
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist