Provider Demographics
NPI:1760976096
Name:ROCK, JENNIFER RENE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENE
Last Name:ROCK
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 1:801 W 5TH AVE STE 323
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2800
Mailing Address - Country:US
Mailing Address - Phone:509-342-3200
Mailing Address - Fax:
Practice Address - Street 1:801 W 5TH AVE STE 323
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2800
Practice Address - Country:US
Practice Address - Phone:509-342-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI196696-30163W00000X
WAAP61114890363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI196696-30OtherWISCONSIN RN LICENSE