Provider Demographics
NPI:1043614837
Name:BROOKS, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
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 1:17302 E R D MIZE RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1819
Mailing Address - Country:US
Mailing Address - Phone:816-521-5395
Mailing Address - Fax:
Practice Address - Street 1:17302 E R D MIZE RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1819
Practice Address - Country:US
Practice Address - Phone:816-521-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014026324235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist