Provider Demographics
NPI:1568473569
Name:SCHAFFER, JACK B (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:B
Last Name:SCHAFFER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 GOODRICH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1907
Mailing Address - Country:US
Mailing Address - Phone:651-699-4751
Mailing Address - Fax:651-699-0826
Practice Address - Street 1:1790 GOODRICH AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1907
Practice Address - Country:US
Practice Address - Phone:651-699-4751
Practice Address - Fax:651-699-0826
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0311103TH0004X, 103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4313086Medicaid