Provider Demographics
NPI:1629379383
Name:SHAVER, JACQUELYN DAINE
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:DAINE
Last Name:SHAVER
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 1:5004 SE 86TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-6197
Mailing Address - Country:US
Mailing Address - Phone:405-417-8459
Mailing Address - Fax:
Practice Address - Street 1:5004 SE 86TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-6197
Practice Address - Country:US
Practice Address - Phone:405-417-8459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health