MEDICARE: MS. JACQUELINE L BROCKMAN RD, CDN, CLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	933767	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	933767	OTHER	NY	CDR

General Provider Information

NPI Number	:	1639381262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACQUELINE L BROCKMAN RD, CDN, CLT

Provider Business Mailing Address
First Line	:	1818 NEWKIRK AVE
Second Line	:	APT 6W
City	:	BROOKLYN
State	:	NY
Zip	:	11226-7359
Country	:	US
Telephone Number	:	561-827-0372
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 NEWKIRK AVE
Second Line	:	APT 6W
City	:	BROOKLYN
State	:	NY
Zip	:	11226-7359
Country	:	US
Telephone Number	:	561-827-0372
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	03/25/2022

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