Provider Demographics
NPI:1780085472
Name:JOCK DEROUIN, BRENDA MARIE (MA, CAS)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:MARIE
Last Name:JOCK DEROUIN
Suffix:
Gender:F
Credentials:MA, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14702 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-2162
Mailing Address - Country:US
Mailing Address - Phone:315-646-7074
Mailing Address - Fax:
Practice Address - Street 1:21638 REED RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5048
Practice Address - Country:US
Practice Address - Phone:315-786-0677
Practice Address - Fax:315-836-3782
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist