Provider Demographics
NPI:1295148914
Name:BROCK, JESSICA MARIE (APRN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:BROCK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-8204
Mailing Address - Country:US
Mailing Address - Phone:606-260-8532
Mailing Address - Fax:606-260-8534
Practice Address - Street 1:148 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8204
Practice Address - Country:US
Practice Address - Phone:606-260-8532
Practice Address - Fax:606-260-8534
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008731363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily