Provider Demographics
NPI:1518347392
Name:SHEA, JACQUELYNN
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:
Last Name:SHEA
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 1:4538 W CRAIG RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-2508
Mailing Address - Country:US
Mailing Address - Phone:702-486-9850
Mailing Address - Fax:702-486-5630
Practice Address - Street 1:4538 W CRAIG RD
Practice Address - Street 2:SUITE 290
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-2508
Practice Address - Country:US
Practice Address - Phone:702-486-9850
Practice Address - Fax:702-486-5630
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator