Provider Demographics
NPI:1609848100
Name:BROCK, JENNIFER GWYNN (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:GWYNN
Last Name:BROCK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
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Mailing Address - Street 1:657 BEN WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-9202
Mailing Address - Country:US
Mailing Address - Phone:910-455-4038
Mailing Address - Fax:910-324-1426
Practice Address - Street 1:103 MILLS ST
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:NC
Practice Address - Zip Code:28574-8307
Practice Address - Country:US
Practice Address - Phone:910-938-1114
Practice Address - Fax:910-455-4038
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC004237101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional