Provider Demographics
NPI:1053540450
Name:BROCK, JESSICA NICOLE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:BROCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7987
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36670-0987
Mailing Address - Country:US
Mailing Address - Phone:251-633-0573
Mailing Address - Fax:251-633-7367
Practice Address - Street 1:5955 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608
Practice Address - Country:US
Practice Address - Phone:251-633-0573
Practice Address - Fax:251-633-7367
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-106242363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I502393OtherMEDICARE
AL3092229OtherUHC
AL512-05477OtherBCBS
AL134189Medicaid
AL222576Medicaid
AL9582378OtherAETNA
ALP00927530OtherRR MEDICARE
ALZ12803OtherVIVA HEALTH
MS02482035OtherMS MEDICAID
AL510-49658OtherBCBS
AL214094Medicaid
AL512-05479OtherBCBS