Provider Demographics
NPI:1396141909
Name:MOCK, JESSICA GRACE (RN)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:GRACE
Last Name:MOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:GRACE
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:429 MANOR DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:EBENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15931-4917
Mailing Address - Country:US
Mailing Address - Phone:814-472-6060
Mailing Address - Fax:814-472-1293
Practice Address - Street 1:429 MANOR DR
Practice Address - Street 2:SUITE 10
Practice Address - City:EBENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15931-4917
Practice Address - Country:US
Practice Address - Phone:814-472-6060
Practice Address - Fax:814-472-1293
Is Sole Proprietor?:No
Enumeration Date:2014-11-08
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN595939163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse