=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205236254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA BROCKDORFF
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2014
-----------------------------------------------------
Last Update Date | 08/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3111 ELECTRIC AVE
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-8127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-985-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81061 DURFEE ST
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48041-4777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-960-4199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6801097142
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------