Provider Demographics
NPI:1659881084
Name:SHIELDS, JESSICA (BS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CENTRAL AVE STE 406
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2241
Mailing Address - Country:US
Mailing Address - Phone:541-269-0321
Mailing Address - Fax:541-267-0785
Practice Address - Street 1:320 CENTRAL AVE STE 406
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2241
Practice Address - Country:US
Practice Address - Phone:541-269-0321
Practice Address - Fax:541-267-0785
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst