Provider Demographics
NPI:1396078531
Name:BROCK-CARTER, JACQUELINE RENITA
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:RENITA
Last Name:BROCK-CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5028 FABLE ST
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-4019
Mailing Address - Country:US
Mailing Address - Phone:240-838-1978
Mailing Address - Fax:
Practice Address - Street 1:5028 FABLE ST
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-4019
Practice Address - Country:US
Practice Address - Phone:240-838-1978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric Assistant