Provider Demographics
NPI:1982239901
Name:SHIELDS, JERRY ALAN
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ALAN
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 1:131 MADRIGAL ST
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2316
Mailing Address - Country:US
Mailing Address - Phone:707-318-8745
Mailing Address - Fax:
Practice Address - Street 1:1550 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4601
Practice Address - Country:US
Practice Address - Phone:707-236-6696
Practice Address - Fax:707-236-6695
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health