Healthcare Provider Details

I. General information

NPI: 1336139658
Provider Name (Legal Business Name): JENNIFER A SHOCKLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 BRIDGE ST
ELK RAPIDS MI
49629-5110
US

IV. Provider business mailing address

PO BOX 888
ELK RAPIDS MI
49629-0888
US

V. Phone/Fax

Practice location:
  • Phone: 231-264-0399
  • Fax: 231-264-0212
Mailing address:
  • Phone: 231-264-0399
  • Fax: 231-264-0212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301074526
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: