Healthcare Provider Details

I. General information

NPI: 1619825023
Provider Name (Legal Business Name): JONATHAN THOMAS BROCKMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2026
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 JERICHO TPKE STE 240
COMMACK NY
11725-2900
US

IV. Provider business mailing address

20 CUSICK AVE
KINGS PARK NY
11754-4909
US

V. Phone/Fax

Practice location:
  • Phone: 631-486-7788
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP139081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: