Provider Demographics
NPI:1790021095
Name:BROCKENBROUGH, JEAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:
Last Name:BROCKENBROUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 HUNTS POINT RD
Mailing Address - Street 2:
Mailing Address - City:HUNTS POINT
Mailing Address - State:WA
Mailing Address - Zip Code:98004-1114
Mailing Address - Country:US
Mailing Address - Phone:425-454-6432
Mailing Address - Fax:
Practice Address - Street 1:16411 NE 24TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-2427
Practice Address - Country:US
Practice Address - Phone:425-456-5705
Practice Address - Fax:425-456-5702
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00038983163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse