Basic Information
| Provider Information | |||||||||
| NPI: | 1861406423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOCOOK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRADT | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 924 N HOWE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284613038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104573806 | ||||||||
| FaxNumber: | 9104573842 | ||||||||
| Practice Location | |||||||||
| Address1: | 906 N HOWE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104541197 | ||||||||
| FaxNumber: | 9104544330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 2010-00929 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64120751 | 05 | KY | MEDICAID |