Provider Demographics
NPI:1225382443
Name:SHULL, JENNIFER MICHELLE
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:SHULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6905 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2692
Mailing Address - Country:US
Mailing Address - Phone:815-397-4142
Mailing Address - Fax:
Practice Address - Street 1:6905 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2692
Practice Address - Country:US
Practice Address - Phone:815-397-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other