Provider Demographics
NPI:1487912119
Name:GELLOCK, JAMIE JOHNSON
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:JOHNSON
Last Name:GELLOCK
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:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-0151
Mailing Address - Country:US
Mailing Address - Phone:302-652-2455
Mailing Address - Fax:302-322-6251
Practice Address - Street 1:1802 W 4TH STREET
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805
Practice Address - Country:US
Practice Address - Phone:302-655-5822
Practice Address - Fax:302-655-3541
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0010792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine