Provider Demographics
NPI:1134603475
Name:SHETTELL, JACOB HYRUM
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:HYRUM
Last Name:SHETTELL
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 1:337 N BEVERLY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-6314
Mailing Address - Country:US
Mailing Address - Phone:801-318-7376
Mailing Address - Fax:
Practice Address - Street 1:855 S DOBSON RD STE 2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5719
Practice Address - Country:US
Practice Address - Phone:480-783-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-22
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18-1728175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath