Provider Demographics
NPI:1174070387
Name:BROCKMAN, JONATHON (HIS)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SHUMAN BLVD
Mailing Address - Street 2:STE 401
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8458
Mailing Address - Country:US
Mailing Address - Phone:331-229-8208
Mailing Address - Fax:978-303-6824
Practice Address - Street 1:3520 W 75TH ST
Practice Address - Street 2:STE 105
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-4102
Practice Address - Country:US
Practice Address - Phone:816-883-2664
Practice Address - Fax:913-262-4330
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1675237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist