Provider Demographics
NPI:1679074611
Name:MOCK, MARLA JENNINGS
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:JENNINGS
Last Name:MOCK
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 1:301 ARTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1216
Mailing Address - Country:US
Mailing Address - Phone:317-432-9900
Mailing Address - Fax:
Practice Address - Street 1:2791 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-2299
Practice Address - Country:US
Practice Address - Phone:765-483-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator