Basic Information
| Provider Information | |||||||||
| NPI: | 1700297017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | JAMIE | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 59 FLEMING DR | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410518515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594145415 | ||||||||
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| Practice Location | |||||||||
| Address1: | 303 N HURSTBOURNE PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024125847 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2014 | ||||||||
| LastUpdateDate: | 05/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 05729 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | A5875 | KY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.