Healthcare Provider Details

I. General information

NPI: 1669504379
Provider Name (Legal Business Name): JACQUELINE BROCKHOEFT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 SEVERN AVE
METAIRIE LA
70002-5932
US

IV. Provider business mailing address

2525 SEVERN AVE
METAIRIE LA
70002-5932
US

V. Phone/Fax

Practice location:
  • Phone: 504-832-4200
  • Fax: 504-378-5121
Mailing address:
  • Phone: 504-832-4200
  • Fax: 504-378-5121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN059884 AP04027
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN059884
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: