Provider Demographics
NPI:1336139658
Name:SHOCKLEY, JENNIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:ELK RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49629-0888
Mailing Address - Country:US
Mailing Address - Phone:231-264-0399
Mailing Address - Fax:231-264-0212
Practice Address - Street 1:115 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:ELK RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49629-5110
Practice Address - Country:US
Practice Address - Phone:231-264-0399
Practice Address - Fax:231-264-0212
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301074526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4415237Medicaid
MIA56344013Medicare ID - Type Unspecified
MI4415237Medicaid