Basic Information
Provider Information
NPI: 1205848926
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HOCKING
FirstName: JARED
MiddleName: T
NamePrefix:  
NameSuffix:  
Credential: PA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1160 KEPLER DR
Address2: PO BOX 8970
City: GREEN BAY
State: WI
PostalCode: 543088970
CountryCode: US
TelephoneNumber: 9202885555
FaxNumber: 9202885550
Practice Location
Address1: 1160 KEPLER DR
Address2:  
City: GREEN BAY
State: WI
PostalCode: 543118321
CountryCode: US
TelephoneNumber: 9202885555
FaxNumber: 9202885550
Other Information
ProviderEnumerationDate: 08/12/2006
LastUpdateDate: 12/08/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/08/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X1852WIY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

ID Information
IDTypeStateIssuerDescription
4287580005WI MEDICAID


Home