Provider Demographics
NPI:1770521155
Name:JAYNES, SHANE CLINTON (LCSWR)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:CLINTON
Last Name:JAYNES
Suffix:
Gender:M
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 TRUMANSBURG RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-256-7639
Mailing Address - Fax:
Practice Address - Street 1:1481 TRUMANSBURG RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-256-7639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
NYR070758104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA8315Medicare ID - Type Unspecified