Provider Demographics
NPI:1760561856
Name:STOCK, JON (ATC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:STOCK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 33RD AVE. N.
Mailing Address - Street 2:APT. 108
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-0910
Mailing Address - Country:US
Mailing Address - Phone:701-526-3519
Mailing Address - Fax:
Practice Address - Street 1:801 17TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2226
Practice Address - Country:US
Practice Address - Phone:701-446-2447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND278-042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer