Provider Demographics
NPI:1922407246
Name:BROCKETT, JEFFERY JOSEPH (BA)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:JOSEPH
Last Name:BROCKETT
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3527
Mailing Address - Country:US
Mailing Address - Phone:810-422-9406
Mailing Address - Fax:810-410-4678
Practice Address - Street 1:1044 GILBERT ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3527
Practice Address - Country:US
Practice Address - Phone:810-422-9406
Practice Address - Fax:810-410-4678
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)