Provider Demographics
NPI:1437162963
Name:SHANLEY, JENNIFER MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:SHANLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BIRCH ST
Mailing Address - Street 2:# 1
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2120
Mailing Address - Country:US
Mailing Address - Phone:603-247-3291
Mailing Address - Fax:
Practice Address - Street 1:63 RANGE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087-2098
Practice Address - Country:US
Practice Address - Phone:603-893-1500
Practice Address - Fax:603-952-4981
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0766152W00000X
MA4565152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30353272Medicaid
NH7925Medicare ID - Type UnspecifiedMEDICARE #
NH30353272Medicaid