Provider Demographics
NPI:1134298953
Name:BROCKERT, JEFFREY JAMES (DC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JAMES
Last Name:BROCKERT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 SOUTH DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377
Mailing Address - Country:US
Mailing Address - Phone:937-898-2225
Mailing Address - Fax:937-898-8988
Practice Address - Street 1:347 SOUTH DIXIE DR
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377
Practice Address - Country:US
Practice Address - Phone:937-898-2225
Practice Address - Fax:937-898-8988
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDC832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T47211Medicare UPIN
OHBR0487413Medicare ID - Type Unspecified