Provider Demographics
NPI:1033631668
Name:BROOKS, KENNA MARIE
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:MARIE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9611 WASHINGTON BLVD SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-1248
Mailing Address - Country:US
Mailing Address - Phone:928-503-5422
Mailing Address - Fax:
Practice Address - Street 1:612 WOODLAND SQUARE LOOP SE STE 401
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1070
Practice Address - Country:US
Practice Address - Phone:360-999-9053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60792062175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1033631668Medicaid
WA1780913657OtherTELECARE MOBILE OUTREACH TEAM