Healthcare Provider Details

I. General information

NPI: 1376464008
Provider Name (Legal Business Name): JAZALYN BROCKLAND
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W ADAMS ST STE 200
CHICAGO IL
60607-2936
US

IV. Provider business mailing address

4524 OPAL DR
HOFFMAN ESTATES IL
60192-1185
US

V. Phone/Fax

Practice location:
  • Phone: 773-466-1555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number25-481357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: