Provider Demographics
NPI:1548559099
Name:SHACKLEFORD, JARREL LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JARREL
Middle Name:LYNNE
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JARREL
Other - Middle Name:LYNNE
Other - Last Name:TUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-662-8765
Mailing Address - Fax:910-362-9123
Practice Address - Street 1:1814 NEW HANOVER MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5350
Practice Address - Country:US
Practice Address - Phone:910-662-8765
Practice Address - Fax:910-362-9123
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12100363A00000X
RIPA00580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1548559099OtherNEIGHBORHOOD HEALTH PLAN
RI4744074OtherAETNA
RI4744074OtherAETNA