1154664316 NPI number — MRS. JENNIFER KRISTINE BROCK APN

Table of content: MRS. JENNIFER KRISTINE BROCK APN (NPI 1154664316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154664316 NPI number — MRS. JENNIFER KRISTINE BROCK APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
JENNIFER
Provider Middle Name:
KRISTINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
APN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154664316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
617 MARION
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEARCY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-305-9826
Provider Business Mailing Address Fax Number:
501-279-3089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
617 MARION
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEARCY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-305-9826
Provider Business Practice Location Address Fax Number:
501-279-3089
Provider Enumeration Date:
04/05/2013

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: 363L00000X , with the licence number:  S002264 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201840758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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