Provider Demographics
NPI:1245346303
Name:SHALZ, JENNIFER T (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:T
Last Name:SHALZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR
Practice Address - Street 2:SUITE 500
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6302
Practice Address - Country:US
Practice Address - Phone:208-706-7050
Practice Address - Fax:208-706-7059
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20003918Medicare PIN