Provider Demographics
NPI:1801943576
Name:BROTHERTON, JEFFERY T (HIS)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:T
Last Name:BROTHERTON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 SAINT MARKS PLZ STE 6
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6411
Mailing Address - Country:US
Mailing Address - Phone:209-477-9181
Mailing Address - Fax:209-477-9192
Practice Address - Street 1:1545 SAINT MARKS PLZ STE 6
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6411
Practice Address - Country:US
Practice Address - Phone:209-477-9181
Practice Address - Fax:209-477-9192
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3182237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA3182OtherHEARING AID DISPENSERS BOARD