Healthcare Provider Details

I. General information

NPI: 1639150352
Provider Name (Legal Business Name): JANICE LYNN BROCKUS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 E PROMENADE ST
MEXICO MO
65265-2926
US

IV. Provider business mailing address

605 E PROMENADE ST P.O. BOX 957
MEXICO MO
65265-2926
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-1332
  • Fax: 573-581-6652
Mailing address:
  • Phone: 573-581-1332
  • Fax: 573-581-6652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number105762
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: