Provider Demographics
NPI:1730763780
Name:JACOCKS, MARK ALLEN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:JACOCKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7209 HAMILTON ACRES CIR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-8623
Mailing Address - Country:US
Mailing Address - Phone:423-499-9335
Mailing Address - Fax:423-499-9334
Practice Address - Street 1:7209 HAMILTON ACRES CIR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-8623
Practice Address - Country:US
Practice Address - Phone:423-499-9335
Practice Address - Fax:423-499-9334
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4879101Y00000X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional