Healthcare Provider Details

I. General information

NPI: 1861147605
Provider Name (Legal Business Name): JENNIFER SHOEMAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 REYNOLDS RD
GLASGOW KY
42141-1177
US

IV. Provider business mailing address

104 REYNOLDS RD
GLASGOW KY
42141-1177
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-6570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number278021
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: