Provider Demographics
NPI:1780962464
Name:ROCK, JACKIE Z (LCMHC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:Z
Last Name:ROCK
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:Z
Other - Last Name:PAZOOKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:123 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070
Mailing Address - Country:US
Mailing Address - Phone:801-448-7811
Mailing Address - Fax:801-877-0873
Practice Address - Street 1:123 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070
Practice Address - Country:US
Practice Address - Phone:801-448-7811
Practice Address - Fax:801-877-0873
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-28
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5886956-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional