Basic Information
Provider Information | |||||||||
NPI: | 1376759837 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STOCKMAL | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | CHRISTOPHER | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.N. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 1ST ST | ||||||||
Address2: |   | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016023104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087530469 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 72 JAQUES AVE | ||||||||
Address2: |   | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016102476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088601163 | ||||||||
FaxNumber: | 5088601115 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/14/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 198832 | MA | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.