Basic Information
| Provider Information | |||||||||
| NPI: | 1073952446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCKMEYER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALLEN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 575 COPELAND MILL RD | ||||||||
| Address2: | SUITE 1D | ||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430818977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147940481 | ||||||||
| FaxNumber: | 6147943711 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 COPELAND MILL RD | ||||||||
| Address2: | SUITE 1D | ||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430818977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147940481 | ||||||||
| FaxNumber: | 6147943711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 10/21/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA-15761-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261Q00000X | COA-15761-NP | OH | N | Ambulatory Health Care Facilities | Clinic/Center | 261QU0200X | COA-15761-NP | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.