Provider Demographics
NPI:1255984738
Name:SHOCK, JENNA L (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:L
Last Name:SHOCK
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 BROADWAY
Mailing Address - Street 2:BUILDING 19, SUITE 10
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2012
Mailing Address - Country:US
Mailing Address - Phone:260-200-4940
Mailing Address - Fax:949-404-6540
Practice Address - Street 1:1690 BROADWAY
Practice Address - Street 2:BUILDING 19, SUITE 10
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2012
Practice Address - Country:US
Practice Address - Phone:260-200-4940
Practice Address - Fax:949-404-6540
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009466A363LP0808X
IN28184986A163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300031451Medicaid