| NPI | 1538869532 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNA SHOCK Owner 260-200-4940 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family |
| Enumeration Date | 2023-03-08 |
| Last Update Date | 2024-11-19 |