Provider Demographics
NPI:1871949073
Name:BROCK, JACLYNN (LMFT)
Entity type:Individual
Prefix:
First Name:JACLYNN
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JACLYNN
Other - Middle Name:M
Other - Last Name:KOBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:501 S CHERRY AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-4263
Mailing Address - Country:US
Mailing Address - Phone:715-486-8302
Mailing Address - Fax:715-486-9253
Practice Address - Street 1:501 S CHERRY AVE STE 5
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-4263
Practice Address - Country:US
Practice Address - Phone:715-486-8302
Practice Address - Fax:715-486-9253
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1073-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist