Healthcare Provider Details

I. General information

NPI: 1891964086
Provider Name (Legal Business Name): JACK B SCHAFFER PHD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 GOODRICH AVE
SAINT PAUL MN
55105-1907
US

IV. Provider business mailing address

1790 GOODRICH AVE
SAINT PAUL MN
55105-1907
US

V. Phone/Fax

Practice location:
  • Phone: 651-699-4751
  • Fax:
Mailing address:
  • Phone: 651-699-4751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberLP0311
License Number StateMN

VIII. Authorized Official

Name: DR. JACK B SCHAFFER
Title or Position: PRESIDENT
Credential:
Phone: 651-699-4751