Healthcare Provider Details

I. General information

NPI: 1134241227
Provider Name (Legal Business Name): JOHN J BRINKMAN JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7956 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

7956 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-2416
  • Fax:
Mailing address:
  • Phone: 260-436-2416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20042066A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: