Healthcare Provider Details

I. General information

NPI: 1265674121
Provider Name (Legal Business Name): JENNIFER K SHOCKLIE MSN, RN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 10/06/2024
Certification Date: 10/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 SE WASHINGTON ST
HILLSBORO OR
97123-4142
US

IV. Provider business mailing address

5401 N 104TH DR
GLENDALE AZ
85307-4192
US

V. Phone/Fax

Practice location:
  • Phone: 503-755-6703
  • Fax: 503-755-6704
Mailing address:
  • Phone: 623-691-5015
  • Fax: 623-691-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN199413
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10031539
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: