MEDICARE: SHANTELL E JAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1225994478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTELL E JAY

Provider Business Mailing Address
First Line	:	21907 143RD RD
Second Line	:
City	:	LAURELTON
State	:	NY
Zip	:	11413-3114
Country	:	US
Telephone Number	:	929-385-5989
Fax Number	:	205-751-9233

Provider Business Practice Location Address
First Line	:	21907 143RD RD
Second Line	:
City	:	LAURELTON
State	:	NY
Zip	:	11413-3114
Country	:	US
Telephone Number	:	929-385-5989
Fax Number	:	205-751-9233

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2025
Last Update Date	:	01/07/2026

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Directions to “ SHANTELL E JAY ” Practice Location

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