Provider Demographics
NPI:1073636379
Name:BOCK, JANE DENISE (PHD, MFT)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:DENISE
Last Name:BOCK
Suffix:
Gender:F
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12392 CARL ST
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1450
Mailing Address - Country:US
Mailing Address - Phone:818-897-3507
Mailing Address - Fax:
Practice Address - Street 1:1529 EAST PALMDALE BOULEVARD
Practice Address - Street 2:SUITE #210
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550
Practice Address - Country:US
Practice Address - Phone:661-272-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 33609106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACBSC288OtherLA DMH PROVIDER
CA00007473Medicaid
CA00007301Medicaid