Provider Demographics
NPI:1245066158
Name:SHAFFER, JORDAN (CMT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CASSWALL ST
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-5902
Mailing Address - Country:US
Mailing Address - Phone:925-719-6042
Mailing Address - Fax:
Practice Address - Street 1:1340 CLAY ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-2550
Practice Address - Country:US
Practice Address - Phone:925-719-6042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92048225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist