Revive Wellness

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

REVIVE WELLNESS

Doing business as

Jessica Shockman

Practice address

116 W Robert St Ste 2B
Crookston, MN 56716-1709

Phone

(218) 289-7023

NPI assigned

Jan 27, 2023

Last updated

Jan 27, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Jessica Nichole Shockman, LICSWNPI 1821762907

Title

Mental Health Professional

Phone

(218) 289-7023

Specialties & licenses 1

Addresses

Other names 1

• Jessica Shockman Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jessica Nichole Shockman, LICSW

  • Clinical Social Worker
  • Crookston, MN
  • NPI 1821762907
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1674777600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674777600000",
    "number": "1639885171",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "116 W ROBERT ST STE 2B",
            "city": "CROOKSTON",
            "state": "MN",
            "postal_code": "567161709",
            "telephone_number": "218-289-7023"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "116 W ROBERT ST STE 2B",
            "city": "CROOKSTON",
            "state": "MN",
            "postal_code": "567161709",
            "telephone_number": "218-289-7023"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVE WELLNESS",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-01-27",
        "last_updated": "2023-01-27",
        "certification_date": "2023-01-27",
        "status": "A",
        "authorized_official_last_name": "SHOCKMAN",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_middle_name": "NICHOLE",
        "authorized_official_title_or_position": "MENTAL HEALTH PROFESSIONAL",
        "authorized_official_telephone_number": "218-289-7023",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "LICSW"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jessica Shockman",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Paul L Reese, PA
• Thomas Manville Reff
• Allie Jo Reiffenberger, OTD, OTR/L
• Shauna R Reitmeier, LICSW
• Hannah Sue Reski, PA-C
• K Elisabeth Ring, PA
• Riverview Health
• Riverview Healthcare Association (Riverview Health)
• Riverview Healthcare Association
• Riverview Healthcare Association (Riverview Recovery Center)

• Mental Health Clinic/Center (Including Community Mental Health Center) in Crookston, MN
• Providers in Crookston, MN by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.