Provider Demographics
NPI:1831120104
Name:SHAFFER, JERALDENE (NP)
Entity Type:Individual
Prefix:
First Name:JERALDENE
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2354 W NORFOLK RD
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-9788
Mailing Address - Country:US
Mailing Address - Phone:708-748-2260
Mailing Address - Fax:
Practice Address - Street 1:14255 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-2154
Practice Address - Country:US
Practice Address - Phone:708-371-0400
Practice Address - Fax:708-371-5871
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner