Provider Demographics
NPI:1801170220
Name:SHAFFER, JONATHAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 ROBB ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2184
Mailing Address - Country:US
Mailing Address - Phone:303-278-7418
Mailing Address - Fax:303-223-9315
Practice Address - Street 1:6121 W 60TH AVE
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80003-5603
Practice Address - Country:US
Practice Address - Phone:303-420-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019151103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13862744OtherCAQH
COPSY.0004404OtherPROFESSIONAL LICENSE