Provider Demographics
NPI:1659141968
Name:BROCK, JESSE STAYTON (AP DOM)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:STAYTON
Last Name:BROCK
Suffix:
Gender:M
Credentials:AP DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11270 82ND ST E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-2705
Mailing Address - Country:US
Mailing Address - Phone:941-504-2372
Mailing Address - Fax:
Practice Address - Street 1:11270 82ND ST E
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-2705
Practice Address - Country:US
Practice Address - Phone:941-504-2372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4543171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist