Provider Demographics
NPI:1407518475
Name:GREGORY, JODIE BROCK
Entity Type:Individual
Prefix:MRS
First Name:JODIE
Middle Name:BROCK
Last Name:GREGORY
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-893-3210
Mailing Address - Fax:
Practice Address - Street 1:152 E KINDERTON WAY
Practice Address - Street 2:
Practice Address - City:BERMUDA RUN
Practice Address - State:NC
Practice Address - Zip Code:27006-7350
Practice Address - Country:US
Practice Address - Phone:336-893-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC297261163W00000X
NC5015404363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse