Provider Demographics
NPI:1902032535
Name:MOCK, JACOB A (PHARMD, BCGP)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:A
Last Name:MOCK
Suffix:
Gender:M
Credentials:PHARMD, BCGP
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:A
Other - Last Name:MOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1650 COWLES ST
Mailing Address - Street 2:FAIRBANKS MEMORIAL HOSPITAL
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2630 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EIELSON AFB
Practice Address - State:AK
Practice Address - Zip Code:99702-2301
Practice Address - Country:US
Practice Address - Phone:907-377-6606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1020581835G0303X
ORRPH-00131831835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric