MEDICARE: DR. JENNIFER MARIE SHANLEY O.D.

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	152W00000X	Optometrist	0766	NH
2	152W00000X	Optometrist	4565	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437162963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER MARIE SHANLEY O.D.

Provider Business Mailing Address
First Line	:	30 BIRCH ST
Second Line	:	# 1
City	:	DERRY
State	:	NH
Zip	:	03038-2120
Country	:	US
Telephone Number	:	603-247-3291
Fax Number	:

Provider Business Practice Location Address
First Line	:	63 RANGE RD
Second Line	:	SUITE 104
City	:	WINDHAM
State	:	NH
Zip	:	03087-2098
Country	:	US
Telephone Number	:	603-893-1500
Fax Number	:	603-952-4981

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/21/2009

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