Provider Demographics
NPI:1841678216
Name:JARRETT, SHANIQUE NASTASSJA (DO)
Entity type:Individual
Prefix:DR
First Name:SHANIQUE
Middle Name:NASTASSJA
Last Name:JARRETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:3003 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4110
Practice Address - Country:US
Practice Address - Phone:715-735-4200
Practice Address - Fax:715-735-8019
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69031208M00000X, 207Q00000X
PAOT016339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100079353Medicaid