Provider Demographics
NPI:1457176653
Name:SMITH-SHAFFER, JO MARIE
Entity type:Individual
Prefix:
First Name:JO MARIE
Middle Name:
Last Name:SMITH-SHAFFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3923 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-2714
Mailing Address - Country:US
Mailing Address - Phone:219-644-9734
Mailing Address - Fax:
Practice Address - Street 1:3923 ADAMS ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-2714
Practice Address - Country:US
Practice Address - Phone:219-644-9734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)