Provider Demographics
NPI:1306409776
Name:THACKER, JOCK MICHAEL
Entity type:Individual
Prefix:
First Name:JOCK
Middle Name:MICHAEL
Last Name:THACKER
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 1:2600 MILSCOTT DR APT 2307
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6040
Mailing Address - Country:US
Mailing Address - Phone:205-746-2453
Mailing Address - Fax:
Practice Address - Street 1:4201 ST. ANTOINE STREET
Practice Address - Street 2:6C, UNIVERSITY HEALTH CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-577-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-20
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program