Provider Demographics
NPI:1225545452
Name:SHAFFER, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 WELLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-3329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 WELLINGTON PL
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-3329
Practice Address - Country:US
Practice Address - Phone:609-670-1176
Practice Address - Fax:609-670-1176
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNONE207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine