Provider Demographics
NPI:1093139321
Name:BLOCK, TERA JEAN
Entity Type:Individual
Prefix:
First Name:TERA JEAN
Middle Name:
Last Name:BLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERA JEAN
Other - Middle Name:
Other - Last Name:MONGEAU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8233 E STOCKTON BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-8203
Mailing Address - Country:US
Mailing Address - Phone:916-368-3080
Mailing Address - Fax:916-405-6551
Practice Address - Street 1:8233 E STOCKTON BLVD STE D
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-8203
Practice Address - Country:US
Practice Address - Phone:916-368-3080
Practice Address - Fax:916-405-6551
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker