Provider Demographics
NPI:1205879046
Name:SHAFER, JEANNINE L (LCSW)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:L
Last Name:SHAFER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 W WILLOW RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2532
Mailing Address - Country:US
Mailing Address - Phone:580-234-6790
Mailing Address - Fax:580-234-2993
Practice Address - Street 1:1216 W WILLOW RD
Practice Address - Street 2:SUITE F
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2532
Practice Address - Country:US
Practice Address - Phone:580-234-6790
Practice Address - Fax:580-234-2993
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK7903086OtherAETNA