Active NPI
Jessica Nichole Shockman, LICSW
- Clinical Social Worker
- Crookston, MN
National Provider Identifier
1821762907
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 17913
- Practice address
- 603 Bruce St
Crookston, MN 56716-2914 - Phone
- (218) 281-3940
- NPI assigned
- Aug 3, 2021
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 17913 | MN | Primary |
Addresses
Primary practice location
603 Bruce St
Crookston, MN 56716-2914
Mailing address
603 Bruce St
Crookston, MN 56716-2914
Phone (218) 281-3940
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 17913 | Other | MN | LICSW |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | CredibleBH.com | Health Information Exchange (HIE) |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Revive Wellness | Current | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Mental Health Clinic/Center (Including Community Mental Health Center)
- Crookston, MN
- NPI 1639885171
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1627948800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1627948800000",
"number": "1821762907",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "603 BRUCE ST",
"city": "CROOKSTON",
"state": "MN",
"postal_code": "567162914",
"telephone_number": "218-281-3940"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "603 BRUCE ST",
"city": "CROOKSTON",
"state": "MN",
"postal_code": "567162914",
"telephone_number": "218-281-3940"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SHOCKMAN",
"first_name": "JESSICA",
"middle_name": "NICHOLE",
"name_prefix": "Mrs.",
"credential": "LICSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2021-08-03",
"last_updated": "2021-08-03",
"certification_date": "2021-08-03",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "MN",
"license": "17913",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LICSW",
"identifier": "17913",
"state": "MN"
}
],
"endpoints": [
{
"endpointType": "CONNECT",
"endpointTypeDescription": "CONNECT URL",
"endpoint": "CredibleBH.com",
"affiliation": "N",
"endpointDescription": "online hie",
"use": "HIE",
"useDescription": "Health Information Exchange (HIE)",
"address_1": "603 Bruce St",
"city": "Crookston",
"state": "MN",
"country_code": "US",
"postal_code": "567162914",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Crookston, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 3, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.