Provider Demographics
NPI:1861406423
Name:BOCOOK, JESSICA D (DO)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:D
Last Name:BOCOOK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:D
Other - Last Name:BRADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:924 N HOWE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-3038
Mailing Address - Country:US
Mailing Address - Phone:910-457-3806
Mailing Address - Fax:910-457-3842
Practice Address - Street 1:906 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461
Practice Address - Country:US
Practice Address - Phone:910-454-1197
Practice Address - Fax:910-454-4330
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-00929207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64120751Medicaid
KYI65178Medicare UPIN
KYP400018480Medicare PIN
KYP40018483Medicare PIN
KYP400018481Medicare PIN
KYP400018479Medicare PIN
KY64120751Medicaid
KYP400018484Medicare PIN
KYP400018485Medicare PIN
KY0055645Medicare PIN