=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104966183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN PSYCHOLOGY RESOURCES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 FIDALGO AVE
-----------------------------------------------------
City | KENAI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99611-7751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-335-4466
-----------------------------------------------------
Fax | 907-335-4467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1487
-----------------------------------------------------
City | KENAI
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99611-1487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-335-4466
-----------------------------------------------------
Fax | 907-335-4467
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JACQUELINE DAWN BOCK
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 907-335-4466
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 561
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 561
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------