Provider Demographics
NPI:1073962700
Name:BROCKMAN, JESSALYN
Entity Type:Individual
Prefix:
First Name:JESSALYN
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8005 FARNAM DR STE 305
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3426
Mailing Address - Country:US
Mailing Address - Phone:402-390-4111
Mailing Address - Fax:402-390-4115
Practice Address - Street 1:1 EDMUNDSON PL STE 200
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4658
Practice Address - Country:US
Practice Address - Phone:402-390-4111
Practice Address - Fax:402-390-4115
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA120454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily