Healthcare Provider Details

I. General information

NPI: 1164635371
Provider Name (Legal Business Name): JESSICA R. SHOCKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N 6TH ST APT 3
LAFAYETTE IN
47904-4033
US

IV. Provider business mailing address

1000 N 6TH ST APT 3
LAFAYETTE IN
47904-4033
US

V. Phone/Fax

Practice location:
  • Phone: 765-414-8076
  • Fax: 765-428-8040
Mailing address:
  • Phone: 765-414-8076
  • Fax: 765-428-8040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: