Provider Demographics
NPI:1427306703
Name:SHOULDIS, JENNIFER NICOLE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:SHOULDIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:HARLESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:210 BROOKS ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1855
Mailing Address - Country:US
Mailing Address - Phone:304-388-1930
Mailing Address - Fax:304-388-1929
Practice Address - Street 1:210 BROOKS ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1855
Practice Address - Country:US
Practice Address - Phone:304-388-1930
Practice Address - Fax:304-388-1929
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV64722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023952Medicaid
WVWV1751AOtherMEDICARE PTAN