Provider Demographics
NPI:1023308681
Name:SHATTUCK, JESSICA (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:PAOLINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:29 CRAFTS STREET
Mailing Address - Street 2:SUITE 570
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458
Mailing Address - Country:US
Mailing Address - Phone:617-965-8010
Mailing Address - Fax:617-965-8071
Practice Address - Street 1:637 WASHINGTON STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:617-734-6135
Practice Address - Fax:617-734-3744
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19301225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA19301OtherPT LICENSE