MEDICARE: JENNIFER K SHOCKLIE MSN, RN, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	313153	AZ
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	10031539	OR

General Provider Information

NPI Number	:	1265674121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER K SHOCKLIE MSN, RN, PMHNP-BC

Provider Business Mailing Address
First Line	:	5441 S MACADAM AVE STE N
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-3822
Country	:	US
Telephone Number	:	503-707-1053
Fax Number	:	541-512-6127

Provider Business Practice Location Address
First Line	:	5441 S MACADAM AVE STE N
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-3822
Country	:	US
Telephone Number	:	503-707-1053
Fax Number	:	541-512-6127

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2009
Last Update Date	:	06/02/2026

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