Healthcare Provider Details

I. General information

NPI: 1376437129
Provider Name (Legal Business Name): TERRA JACQUELINE MOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N COUNTY FARM RD
WHEATON IL
60187-3977
US

IV. Provider business mailing address

111 N COUNTY FARM RD
WHEATON IL
60187-3988
US

V. Phone/Fax

Practice location:
  • Phone: 630-627-1700
  • Fax:
Mailing address:
  • Phone: 630-682-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: