Provider Demographics
NPI:1609852805
Name:BOCOCK, JENNIFER M (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:BOCOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 NEWMARK DR STE 220
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5400
Mailing Address - Country:US
Mailing Address - Phone:937-436-4658
Mailing Address - Fax:937-436-4984
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080099207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2351824Medicaid
OH4070372OtherMEDICARE PTAN
OH4070373OtherMEDICARE PTAN
OH4070372OtherMEDICARE PTAN