Provider Demographics
NPI:1164635371
Name:SHOCKEY, JESSICA R
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:SHOCKEY
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 1:1000 N 6TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-4033
Mailing Address - Country:US
Mailing Address - Phone:765-414-8076
Mailing Address - Fax:765-428-8040
Practice Address - Street 1:1000 N 6TH ST APT 3
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-4033
Practice Address - Country:US
Practice Address - Phone:765-414-8076
Practice Address - Fax:765-428-8040
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist