MEDICARE: MRS. JEANNETTE SHUPE MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	006764	NY

General Provider Information

NPI Number	:	1336517671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANNETTE SHUPE MS

Provider Business Mailing Address
First Line	:	PO BOX 121
Second Line	:	8 MACLEAN DR
City	:	ROCK TAVERN
State	:	NY
Zip	:	12575-0121
Country	:	US
Telephone Number	:	845-258-0139
Fax Number	:

Provider Business Practice Location Address
First Line	:	8 MACLEAN DR
Second Line	:
City	:	ROCK TAVERN
State	:	NY
Zip	:	12575-0121
Country	:	US
Telephone Number	:	845-258-0139
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2015
Last Update Date	:	09/03/2015

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