Provider Demographics
NPI:1417767021
Name:KLOCK, JACOB RUSSEL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RUSSEL
Last Name:KLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 MOUNT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-7242
Mailing Address - Country:US
Mailing Address - Phone:570-317-4568
Mailing Address - Fax:
Practice Address - Street 1:725 COLUMBIA BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-2360
Practice Address - Country:US
Practice Address - Phone:570-387-6183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP459047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist