Provider Demographics
NPI:1114588175
Name:BROOKS, IESHA NICOLE
Entity Type:Individual
Prefix:
First Name:IESHA
Middle Name:NICOLE
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 1:3450 3RD ST STE 1C
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94124-1444
Mailing Address - Country:US
Mailing Address - Phone:415-437-3990
Mailing Address - Fax:415-437-3994
Practice Address - Street 1:3450 3RD ST STE 1C
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94124-1444
Practice Address - Country:US
Practice Address - Phone:415-437-3990
Practice Address - Fax:415-437-3994
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
390200000X
CA125623106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program