1255984738 NPI number — MRS. JENNA L SHOCK MSN, APRN, PMHNP-BC

Table of content: MRS. JENNA L SHOCK MSN, APRN, PMHNP-BC (NPI 1255984738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255984738 NPI number — MRS. JENNA L SHOCK MSN, APRN, PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOCK
Provider First Name:
JENNA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, APRN, PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255984738
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1690 BROADWAY
Provider Second Line Business Mailing Address:
BUILDING 19, SUITE 10
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46802-2012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-200-4940
Provider Business Mailing Address Fax Number:
949-404-6540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1690 BROADWAY
Provider Second Line Business Practice Location Address:
BUILDING 19, SUITE 10
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46802-2012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-200-4940
Provider Business Practice Location Address Fax Number:
949-404-6540
Provider Enumeration Date:
07/23/2019

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: 363LP0808X , with the licence number:  71009466A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WP0808X , with the licence number: 28184986A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 300031451 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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