Provider Demographics
NPI:1780816223
Name:HANCOCK, JONATHAN DANIEL
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DANIEL
Last Name:HANCOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:STEDMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28391-0727
Mailing Address - Country:US
Mailing Address - Phone:910-491-4530
Mailing Address - Fax:910-491-6093
Practice Address - Street 1:1074 SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-1766
Practice Address - Country:US
Practice Address - Phone:910-491-4530
Practice Address - Fax:910-491-6093
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004563363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5004563OtherNC LISCENSE