Provider Demographics
NPI:1235522244
Name:SHANK, JACQUELYNN MARY
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:MARY
Last Name:SHANK
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 1:6801 BRECKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-5032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5001 ROCKSIDE RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131
Practice Address - Country:US
Practice Address - Phone:216-986-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant