Provider Demographics
NPI:1285426361
Name:SHEALY, JENNIFER ANNE (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:SHEALY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16412 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WEED
Mailing Address - State:CA
Mailing Address - Zip Code:96094-9482
Mailing Address - Country:US
Mailing Address - Phone:801-725-5789
Mailing Address - Fax:
Practice Address - Street 1:2020 MILLIGAN WAY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5894
Practice Address - Country:US
Practice Address - Phone:541-858-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-22
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95334819207PE0004X, 208D00000X
OR201508365RN207PE0004X
CA95035588207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10045481OtherOREGON NURSE PRACTITIONER LICENSE
OR15295OtherNURSE PRACTITIONER PRESCRIPTIVE AUTHORITY NUMBER
CA95035588OtherGENERAL PRACTICE
CA95035588OtherCALIFORNIA FURNISHING LICENSE