Provider Demographics
NPI:1922760842
Name:SHAFFER, JACOB GREGORY
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:GREGORY
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WARREN ST APT H32
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6912
Mailing Address - Country:US
Mailing Address - Phone:507-828-6332
Mailing Address - Fax:
Practice Address - Street 1:201 N BROAD ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3585
Practice Address - Country:US
Practice Address - Phone:507-828-6332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306194101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)