Provider Demographics
NPI:1083977151
Name:BARTOCK, JESSICA L (DO,)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BARTOCK
Suffix:
Gender:F
Credentials:DO,
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Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 E 7TH ST STE F
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2518
Practice Address - Country:US
Practice Address - Phone:260-920-2710
Practice Address - Fax:260-920-2043
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101019735208600000X
IN02006582A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery