Provider Demographics
NPI:1790922755
Name:ROCK, JENELLE CECILIA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:CECILIA
Last Name:ROCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:CECILIA
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1950 NORTHWESTERN AVE S
Mailing Address - Street 2:STE 102
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7615
Mailing Address - Country:US
Mailing Address - Phone:651-430-3800
Mailing Address - Fax:651-430-3827
Practice Address - Street 1:1950 NORTHWESTERN AVE S
Practice Address - Street 2:SUITE 102
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-7590
Practice Address - Country:US
Practice Address - Phone:651-430-3800
Practice Address - Fax:651-430-3827
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12053363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47061995513Medicaid
NE47061995513Medicaid