Provider Demographics
NPI:1558910943
Name:JOCK, LISA M
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:JOCK
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 1:1276 SKIPPER RUN SW
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462
Mailing Address - Country:US
Mailing Address - Phone:910-842-6769
Mailing Address - Fax:
Practice Address - Street 1:1276 SKIPPER RUN SW
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462
Practice Address - Country:US
Practice Address - Phone:910-842-6769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider