Provider Demographics
NPI:1356909360
Name:BROCK, JESSICA BETH (MS)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:BETH
Last Name:BROCK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 GWENDOLYN PL
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-3220
Mailing Address - Country:US
Mailing Address - Phone:631-525-3202
Mailing Address - Fax:
Practice Address - Street 1:42 GWENDOLYN PL
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-3220
Practice Address - Country:US
Practice Address - Phone:631-525-3202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency