Provider Demographics
NPI:1275879892
Name:SHAFFER, JORDAN LORRAINE
Entity Type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:LORRAINE
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 1:306 N. KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526
Mailing Address - Country:US
Mailing Address - Phone:312-965-2997
Mailing Address - Fax:
Practice Address - Street 1:30 E ELM ST
Practice Address - Street 2:APT 19A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1042
Practice Address - Country:US
Practice Address - Phone:630-908-0946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst