Provider Demographics
NPI:1952323032
Name:JOCK, SUSAN ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:JOCK
Suffix:
Gender:F
Credentials:NP
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 940
Mailing Address - Street 2:805 W CEDAR ST
Mailing Address - City:STANDISH
Mailing Address - State:MI
Mailing Address - Zip Code:48658-0940
Mailing Address - Country:US
Mailing Address - Phone:989-846-4535
Mailing Address - Fax:989-846-6580
Practice Address - Street 1:805 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658-9526
Practice Address - Country:US
Practice Address - Phone:989-846-4535
Practice Address - Fax:989-846-6580
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47004149300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4615739Medicaid
MI0N73720Medicare ID - Type Unspecified
MIP92003Medicare UPIN