Provider Demographics
NPI:1639381262
Name:BROCKMAN, JACQUELINE L (RD, CDN, CLT)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:L
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:RD, CDN, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 NEWKIRK AVE
Mailing Address - Street 2:APT 6W
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-7359
Mailing Address - Country:US
Mailing Address - Phone:561-827-0372
Mailing Address - Fax:
Practice Address - Street 1:1818 NEWKIRK AVE
Practice Address - Street 2:APT 6W
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-7359
Practice Address - Country:US
Practice Address - Phone:561-827-0372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY933767133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY933767OtherCDR