Provider Demographics
NPI:1154664316
Name:BROCK, JENNIFER KRISTINE (APN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KRISTINE
Last Name:BROCK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:617 MARION
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143
Mailing Address - Country:US
Mailing Address - Phone:501-305-9826
Mailing Address - Fax:501-279-3089
Practice Address - Street 1:617 MARION
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143
Practice Address - Country:US
Practice Address - Phone:501-305-9826
Practice Address - Fax:501-279-3089
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARS002264363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR201840758Medicaid