Provider Demographics
NPI:1700125531
Name:KLOCK, JENNIFER SUE (RN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:SUE
Last Name:KLOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10571 WHITE ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:GARRETTSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44231-1071
Mailing Address - Country:US
Mailing Address - Phone:330-527-6081
Mailing Address - Fax:
Practice Address - Street 1:10571 WHITE ST UNIT 4
Practice Address - Street 2:
Practice Address - City:GARRETTSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44231-1071
Practice Address - Country:US
Practice Address - Phone:330-527-6081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.283543163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse