Provider Demographics
NPI:1477104792
Name:JESSOP, SHALAE HERBERT
Entity Type:Individual
Prefix:
First Name:SHALAE
Middle Name:HERBERT
Last Name:JESSOP
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:PO BOX 410021
Mailing Address - Street 2:
Mailing Address - City:PINESDALE
Mailing Address - State:MT
Mailing Address - Zip Code:59841-0021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3687 VETERANS DR
Practice Address - Street 2:
Practice Address - City:FORT HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636-9700
Practice Address - Country:US
Practice Address - Phone:406-447-6187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty