Provider Demographics
NPI:1518202944
Name:SHACKELFORD, JENNIFER LYNN (ACNP-BC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:ACNP-BC
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 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:858-249-6749
Mailing Address - Fax:
Practice Address - Street 1:165 CAMBRIDGE ST
Practice Address - Street 2:SUITE 810
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2783
Practice Address - Country:US
Practice Address - Phone:617-726-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN219976363LA2100X
CANP95004457363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care