Provider Demographics
NPI:1629576897
Name:SHAFFER, JESSICA (MA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:KIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:509 MOUNT OLYMPUS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-2413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1823 BUSINESS PARK BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1230
Practice Address - Country:US
Practice Address - Phone:386-254-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)