Provider Demographics
NPI:1265674121
Name:SHOCKLIE, JENNIFER K (MSN, RN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:SHOCKLIE
Suffix:
Gender:F
Credentials:MSN, RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5401 N 104TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-4192
Mailing Address - Country:US
Mailing Address - Phone:623-691-5015
Mailing Address - Fax:623-691-5020
Practice Address - Street 1:535 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4142
Practice Address - Country:US
Practice Address - Phone:503-755-6703
Practice Address - Fax:503-755-6704
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2024-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZRN199413163WP0808X
OR10031539363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health