Provider Demographics
NPI:1568004851
Name:MOCK, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MOCK
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 1:190 MADISON AVE NE
Mailing Address - Street 2:
Mailing Address - City:LUDOWICI
Mailing Address - State:GA
Mailing Address - Zip Code:31316-5610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 MADISON AVE NE
Practice Address - Street 2:
Practice Address - City:LUDOWICI
Practice Address - State:GA
Practice Address - Zip Code:31316-5610
Practice Address - Country:US
Practice Address - Phone:912-271-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider