Healthcare Provider Details

I. General information

NPI: 1699925537
Provider Name (Legal Business Name): JESSICA GRAY BROCK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA GRAY EATON

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 LAKE BOONE TRL STE 220
RALEIGH NC
27607-6685
US

IV. Provider business mailing address

4207 LAKE BOONE TRL STE 220
RALEIGH NC
27607-6685
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-1410
  • Fax:
Mailing address:
  • Phone: 919-784-1410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01386
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: