Healthcare Provider Details

I. General information

NPI: 1417470089
Provider Name (Legal Business Name): JACOB SHAFFER APRN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 W WAYNE ST
PAULDING OH
45879-1544
US

IV. Provider business mailing address

7038 COUNTY ROAD 424
ANTWERP OH
45813-9520
US

V. Phone/Fax

Practice location:
  • Phone: 800-741-1743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.021349
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: