Provider Demographics
NPI:1104009620
Name:BROOKS, JONATHAN KEITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:KEITH
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1532
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-1532
Mailing Address - Country:US
Mailing Address - Phone:303-838-7595
Mailing Address - Fax:
Practice Address - Street 1:29029 UPPER BEAR CREEK RD STE 305
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7722
Practice Address - Country:US
Practice Address - Phone:303-838-7595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2815103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical