Provider Demographics
NPI:1558653790
Name:BROCKINGTON, JENNIFER RIEDEL (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RIEDEL
Last Name:BROCKINGTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:405 BELCHER ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35042-2946
Mailing Address - Country:US
Mailing Address - Phone:205-926-2992
Mailing Address - Fax:205-316-7675
Practice Address - Street 1:1308 TUSCALOOSA AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1948
Practice Address - Country:US
Practice Address - Phone:205-679-6325
Practice Address - Fax:205-783-8600
Is Sole Proprietor?:No
Enumeration Date:2011-05-06
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8862207Q00000X
ALDO.2973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine