Healthcare Provider Details

I. General information

NPI: 1275879892
Provider Name (Legal Business Name): MS. JORDAN LORRAINE SHAFFER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E ELM ST APT 19A
CHICAGO IL
60611-1042
US

IV. Provider business mailing address

306 N. KENSINGTON AVE
LA GRANGE PARK IL
60526
US

V. Phone/Fax

Practice location:
  • Phone: 630-908-0946
  • Fax:
Mailing address:
  • Phone: 312-965-2997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: