Provider Demographics
NPI:1215299375
Name:SHOCKLEY, JESSICA (COA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SUGAR CAMP CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1962
Mailing Address - Country:US
Mailing Address - Phone:937-222-3937
Mailing Address - Fax:937-223-5254
Practice Address - Street 1:105 SUGAR CAMP CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1962
Practice Address - Country:US
Practice Address - Phone:937-222-3937
Practice Address - Fax:937-223-5254
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH180446156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant