Provider Demographics
NPI:1427095900
Name:BOCK, JACQUELINE DAWN (PHD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DAWN
Last Name:BOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47294 PROGRESS CT
Mailing Address - Street 2:STE C
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8322
Mailing Address - Country:US
Mailing Address - Phone:907-262-4470
Mailing Address - Fax:907-262-4467
Practice Address - Street 1:215 FIDALGO AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7751
Practice Address - Country:US
Practice Address - Phone:907-335-4466
Practice Address - Fax:907-335-4467
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK561103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist