Provider Demographics
NPI:1588604847
Name:FUNK, JEANNE BROCKMYER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:BROCKMYER
Last Name:FUNK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WEST BANCROFT
Mailing Address - Street 2:MS 948
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3390
Mailing Address - Country:US
Mailing Address - Phone:419-530-4392
Mailing Address - Fax:419-530-4392
Practice Address - Street 1:2801 WEST BANCROFT
Practice Address - Street 2:MS 948
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3390
Practice Address - Country:US
Practice Address - Phone:419-530-4392
Practice Address - Fax:419-530-4392
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2732103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0394747Medicaid
OHFU0474821Medicare ID - Type Unspecified