Provider Demographics
NPI:1164465712
Name:BROOKS, JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 S BAILEY ST
Mailing Address - Street 2:STE 104
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6330
Mailing Address - Country:US
Mailing Address - Phone:907-746-2345
Mailing Address - Fax:
Practice Address - Street 1:634 S BAILEY ST
Practice Address - Street 2:STE 104
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6330
Practice Address - Country:US
Practice Address - Phone:907-746-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4291207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1019926Medicaid
AKK160764Medicare PIN
AKMD98812Medicaid