Provider Demographics
NPI:1396949855
Name:SHANTZ, JERI LOU (EDD)
Entity type:Individual
Prefix:DR
First Name:JERI
Middle Name:LOU
Last Name:SHANTZ
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:DR
Other - First Name:JERI
Other - Middle Name:LOU
Other - Last Name:SCHWEIGLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:1300 114TH AVE SE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6942
Mailing Address - Country:US
Mailing Address - Phone:425-454-2835
Mailing Address - Fax:425-454-2315
Practice Address - Street 1:1300 114TH AVE SE
Practice Address - Street 2:SUITE 102
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6942
Practice Address - Country:US
Practice Address - Phone:425-454-2835
Practice Address - Fax:425-454-2315
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1349174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8878148Medicare PIN
WA217000698Medicare PIN