Healthcare Provider Details

I. General information

NPI: 1275869612
Provider Name (Legal Business Name): JESSICA ELIZABETH SHABO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 SOUTH ORANGE AVE BHSB E-1447 PSYCHIATRY DEPARTMENT
NEWARK NJ
07101-1709
US

IV. Provider business mailing address

183 SOUTH ORANGE AVE BHSB E-1447 PSYCHIATRY DEPARTMENT
NEWARK NJ
07101-1709
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-4678
  • Fax:
Mailing address:
  • Phone: 973-972-4678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number25MA08646100
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: