Provider Demographics
NPI:1871220061
Name:HANCOCK, JAKE
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:HANCOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 OGDEN DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3713
Mailing Address - Country:US
Mailing Address - Phone:321-412-4653
Mailing Address - Fax:
Practice Address - Street 1:3820 MURRELL RD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-4741
Practice Address - Country:US
Practice Address - Phone:321-636-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-06
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS64518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist