Basic Information
Provider Information | |||||||||
NPI: | 1851379317 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHOOK | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2323 W ROSE GARDEN LN | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850272530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6025216252 | ||||||||
FaxNumber: | 6238425640 | ||||||||
Practice Location | |||||||||
Address1: | 19020 33RD AVE W | ||||||||
Address2: | STE 210 | ||||||||
City: | LYNNWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 980364746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255631500 | ||||||||
FaxNumber: | 4255631374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/05/2006 | ||||||||
LastUpdateDate: | 01/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD00036174 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 27518 | AZ | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 201630 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 8234718 | 05 | WA |   | MEDICAID | 194628 | 01 | WA | L&I PROVIDER NUMBER | OTHER |