Provider Demographics
NPI:1780848903
Name:MOCK, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MOCK
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 1:326 COMMERCE ST E
Mailing Address - Street 2:
Mailing Address - City:FORT GAINES
Mailing Address - State:GA
Mailing Address - Zip Code:39851-3331
Mailing Address - Country:US
Mailing Address - Phone:229-768-3517
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVEUNE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-596-5583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker