Provider Demographics
NPI:1174001028
Name:FROCK, JODI LYNN (RBT-18-61871)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:LYNN
Last Name:FROCK
Suffix:
Gender:F
Credentials:RBT-18-61871
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4061 SUZANNE DR
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-3735
Mailing Address - Country:US
Mailing Address - Phone:228-396-4434
Mailing Address - Fax:
Practice Address - Street 1:4061 SUZANNE DR
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-3735
Practice Address - Country:US
Practice Address - Phone:228-396-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-18-61871106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician