Provider Demographics
NPI:1336690460
Name:SHEAFFER, JACKLYN
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:SHEAFFER
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 1:8630 MOHAWK CT
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49346-9644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8630 MOHAWK CT
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:MI
Practice Address - Zip Code:49346-9644
Practice Address - Country:US
Practice Address - Phone:989-245-0903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer