Provider Demographics
NPI:1003948928
Name:SHATTUCK, JEANETTE LOUISE (OTR L)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:LOUISE
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4772 KATELLA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2681
Mailing Address - Country:US
Mailing Address - Phone:562-430-8700
Mailing Address - Fax:562-430-8760
Practice Address - Street 1:4772 KATELLA AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2681
Practice Address - Country:US
Practice Address - Phone:562-430-8700
Practice Address - Fax:562-430-8760
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAA358119225000000X, 225X00000X, 225XE1200X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5481969OtherFIRST HEALTH ID
CAOT0048180OtherBLUE SHIELD PIN
CAWOT4818AMedicare ID - Type UnspecifiedMEDICARE PPIN