Provider Demographics
NPI:1174697700
Name:SHOOK, JENNIFER D (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:D
Last Name:SHOOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 20TH
Mailing Address - Street 2:KIDS HOPE UNITED
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-4128
Mailing Address - Country:US
Mailing Address - Phone:618-204-1986
Mailing Address - Fax:618-242-1150
Practice Address - Street 1:111 SOUTH 20TH
Practice Address - Street 2:KIDS HOPE UNITED
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-204-1986
Practice Address - Fax:618-242-1150
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0112351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL076492000Medicare UPIN
IL704187Medicare UPIN
IL243944Medicare UPIN
IL161888Medicare UPIN