Provider Demographics
NPI:1740922657
Name:SHIELDS, JEFFREY JEROME
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JEROME
Last Name:SHIELDS
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 1:201 160TH ST S STE 301
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8508
Mailing Address - Country:US
Mailing Address - Phone:253-610-2060
Mailing Address - Fax:
Practice Address - Street 1:201 160TH ST S
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8508
Practice Address - Country:US
Practice Address - Phone:253-316-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61436144101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health