Provider Demographics
NPI:1093402117
Name:SCHOCK, JASTEN KEITH
Entity Type:Individual
Prefix:
First Name:JASTEN
Middle Name:KEITH
Last Name:SCHOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 ELBOWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5712
Mailing Address - Country:US
Mailing Address - Phone:701-751-8260
Mailing Address - Fax:
Practice Address - Street 1:1308 ELBOWOOD LN
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5712
Practice Address - Country:US
Practice Address - Phone:701-751-8260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No172A00000XOther Service ProvidersDriver