Healthcare Provider Details

I. General information

NPI: 1295374148
Provider Name (Legal Business Name): LOGAN JAY SHOCKLEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2019
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

1050 W 10TH ST
ROLLA MO
65401-2905
US

V. Phone/Fax

Practice location:
  • Phone: 855-406-3324
  • Fax: 573-458-8363
Mailing address:
  • Phone: 573-364-9000
  • Fax: 573-426-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2016022013
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020003116
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: