Basic Information
Provider Information | |||||||||
NPI: | 1073551248 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROCK | ||||||||
FirstName: | JARED | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 775383 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606775383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123753000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4001 W GOELLER BLVD STE A | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | IN | ||||||||
PostalCode: | 472018309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123753330 | ||||||||
FaxNumber: | 8123753329 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2006 | ||||||||
LastUpdateDate: | 10/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10000575A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 000000991456 | 01 | IN | ANTHEM PIN | OTHER | 10000575A | 01 | IN | INDIANA LICENSE | OTHER |