1528474905 NPI number — JENNIFER M SHOBACK CNM

Table of content: JENNIFER M SHOBACK CNM (NPI 1528474905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528474905 NPI number — JENNIFER M SHOBACK CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOBACK
Provider First Name:
JENNIFER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVIDSON
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528474905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N ACADEMY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17822-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-271-6144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1155 E MOUNTAIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702-7906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-808-7916
Provider Business Practice Location Address Fax Number:
570-808-6006
Provider Enumeration Date:
07/07/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  MW010463 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367A00000X , with the licence number: 001626 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)