Provider Demographics
NPI:1770886103
Name:CERVANTES SHUFFIELD, JENNIFER (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:CERVANTES SHUFFIELD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 GRANVILLE ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-5002
Mailing Address - Country:US
Mailing Address - Phone:208-874-2409
Mailing Address - Fax:
Practice Address - Street 1:2606 GRANVILLE ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-5002
Practice Address - Country:US
Practice Address - Phone:208-874-2409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-287181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical