Provider Demographics
NPI:1720537822
Name:SHULLICK, JAIME VAUGHN
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:VAUGHN
Last Name:SHULLICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:LEE
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:618 N KNIGHT DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CA
Mailing Address - Zip Code:93523-2735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3685
Practice Address - Country:US
Practice Address - Phone:661-945-0884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43070208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation