Healthcare Provider Details

I. General information

NPI: 1609848100
Provider Name (Legal Business Name): JENNIFER GWYNN BROCK MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MILLS ST
RICHLANDS NC
28574-8307
US

IV. Provider business mailing address

657 BEN WILLIAMS RD
JACKSONVILLE NC
28540-9202
US

V. Phone/Fax

Practice location:
  • Phone: 910-938-1114
  • Fax: 910-455-4038
Mailing address:
  • Phone: 910-455-4038
  • Fax: 910-324-1426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC004237
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: