Provider Demographics
NPI:1184010928
Name:BROCKHUIZEN, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BROCKHUIZEN
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 1:1008 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-1325
Mailing Address - Country:US
Mailing Address - Phone:315-576-4781
Mailing Address - Fax:
Practice Address - Street 1:635 W WATER ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905
Practice Address - Country:US
Practice Address - Phone:607-734-4333
Practice Address - Fax:607-754-0658
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0000915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor