Provider Demographics
NPI:1568444347
Name:BRODSKY, JACQUELINE JEANETTE (NP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:JEANETTE
Last Name:BRODSKY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8144 E CANDLEBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-4500
Mailing Address - Country:US
Mailing Address - Phone:714-639-0992
Mailing Address - Fax:949-480-4246
Practice Address - Street 1:1 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-8081
Practice Address - Country:US
Practice Address - Phone:949-480-4143
Practice Address - Fax:949-480-4246
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA166872363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care