Basic Information
| Provider Information | |||||||||
| NPI: | 1053540450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7987 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366700987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330573 | ||||||||
| FaxNumber: | 2516337367 | ||||||||
| Practice Location | |||||||||
| Address1: | 5955 AIRPORT BLVD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330573 | ||||||||
| FaxNumber: | 2516337367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2009 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1-106242 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 1-106242 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 02482035 | 01 | MS | MS MEDICAID | OTHER | 510-49658 | 01 | AL | BCBS | OTHER | 134189 | 05 | AL | MEDICAID | 102I502393 | 01 | AL | MEDICARE | OTHER | 214094 | 05 | AL | MEDICAID | P00927530 | 01 | AL | RR MEDICARE | OTHER | Z12803 | 01 | AL | VIVA HEALTH | OTHER | 512-05477 | 01 | AL | BCBS | OTHER | 9582378 | 01 | AL | AETNA | OTHER | 3092229 | 01 | AL | UHC | OTHER | 512-05479 | 01 | AL | BCBS | OTHER | 222576 | 05 | AL | MEDICAID |