Healthcare Provider Details

I. General information

NPI: 1922407246
Provider Name (Legal Business Name): JEFFERY JOSEPH BROCKETT B.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 GILBERT ST
FLINT MI
48532-3527
US

IV. Provider business mailing address

1044 GILBERT ST
FLINT MI
48532-3527
US

V. Phone/Fax

Practice location:
  • Phone: 810-422-9406
  • Fax: 810-410-4678
Mailing address:
  • Phone: 810-422-9406
  • Fax: 810-410-4678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: