Provider Demographics
NPI:1346323870
Name:BROCKMAN, JENNIFER ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ELAINE
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8525
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-0525
Mailing Address - Country:US
Mailing Address - Phone:314-843-7500
Mailing Address - Fax:314-843-7503
Practice Address - Street 1:321 W PROMENADE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2719
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:573-582-1212
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040035022084F0202X
CAA960052084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA96005OtherSTATE LICENSE
MO2004003502OtherMISSOURI STATE LICENSE
MO2004003502OtherMISSOURI STATE LICENSE