Provider Demographics
NPI:1962429654
Name:SHETLER, JAY R (PSYD, HSPP)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:R
Last Name:SHETLER
Suffix:
Gender:M
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5907
Mailing Address - Country:US
Mailing Address - Phone:574-534-2161
Mailing Address - Fax:574-534-3887
Practice Address - Street 1:1930 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5907
Practice Address - Country:US
Practice Address - Phone:574-534-2161
Practice Address - Fax:574-534-3887
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041401A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200270630AMedicaid