1861406423 NPI number — DR. JESSICA D BOCOOK D.O.

Table of content: DR. JESSICA D BOCOOK D.O. (NPI 1861406423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861406423 NPI number — DR. JESSICA D BOCOOK D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOCOOK
Provider First Name:
JESSICA
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRADT
Provider Other First Name:
JESSICA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861406423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 N HOWE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHPORT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28461-3038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-457-3806
Provider Business Mailing Address Fax Number:
910-457-3842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
906 N HOWE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHPORT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-454-1197
Provider Business Practice Location Address Fax Number:
910-454-4330
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  2010-00929 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64120751 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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