Healthcare Provider Details

I. General information

NPI: 1023032729
Provider Name (Legal Business Name): JENNIFER ANNE SHATTUCK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 RIVERSIDE DR
JOHNSON CITY NY
13790-2745
US

IV. Provider business mailing address

260 RIVERSIDE DR
JOHNSON CITY NY
13790-2745
US

V. Phone/Fax

Practice location:
  • Phone: 607-798-7811
  • Fax:
Mailing address:
  • Phone: 607-798-7811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number334772
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: