Provider Demographics
NPI:1386920304
Name:SHATTUCK, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHATTUCK
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 1:108 EDUCATION DR
Mailing Address - Street 2:MPMS ROOM 127
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12303-1238
Mailing Address - Country:US
Mailing Address - Phone:518-881-3413
Mailing Address - Fax:518-881-3411
Practice Address - Street 1:108 EDUCATION DR
Practice Address - Street 2:MPMS ROOM 127
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12303-1238
Practice Address - Country:US
Practice Address - Phone:518-881-3413
Practice Address - Fax:518-881-3411
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY516385163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01406986Medicaid