Provider Demographics
NPI:1124358379
Name:SHOOK, JANICE VICTORIA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:VICTORIA
Last Name:SHOOK
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 OLSON AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-5825
Mailing Address - Country:US
Mailing Address - Phone:228-860-4407
Mailing Address - Fax:
Practice Address - Street 1:119 OLSON AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-5825
Practice Address - Country:US
Practice Address - Phone:228-860-4407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0575235Z00000X
TNSP001495235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist