Provider Demographics
NPI:1467197509
Name:BROCK, JENNIFER B
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:BROCK
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 245
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OR
Mailing Address - Zip Code:97818-0245
Mailing Address - Country:US
Mailing Address - Phone:541-303-4658
Mailing Address - Fax:
Practice Address - Street 1:71840 MEADOW LOOP
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OR
Practice Address - Zip Code:97818-9668
Practice Address - Country:US
Practice Address - Phone:541-303-4658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000004247175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist