Provider Demographics
NPI:1528474905
Name:SHOBACK, JENNIFER M (CNM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:SHOBACK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:1155 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7906
Practice Address - Country:US
Practice Address - Phone:570-808-7916
Practice Address - Fax:570-808-6006
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001626367A00000X
PAMW010463367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife