Provider Demographics
NPI:1154996775
Name:MOCK, KATHRYN JEAN (RDN)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEAN
Last Name:MOCK
Suffix:
Gender:
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425-1717
Practice Address - Country:US
Practice Address - Phone:616-638-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT98837133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered