Provider Demographics
NPI:1144566555
Name:BOCK, JILL MARIE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:BOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2347 HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3849
Mailing Address - Country:US
Mailing Address - Phone:920-253-6744
Mailing Address - Fax:
Practice Address - Street 1:N2347 HICKORY RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3849
Practice Address - Country:US
Practice Address - Phone:920-253-6744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304900-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse