Healthcare Provider Details

I. General information

NPI: 1467067371
Provider Name (Legal Business Name): JESSICA SHACKLETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 MANATEE AVE W
BRADENTON FL
34205-8805
US

IV. Provider business mailing address

367 S GULPH RD; ATT IPM CREDENTIALING
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 941-748-2277
  • Fax: 941-748-1958
Mailing address:
  • Phone: 941-748-2277
  • Fax: 941-748-8714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11009058
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: