Provider Demographics
NPI:1174410831
Name:JEFFERSON, BROOKE (MA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MA
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 1442
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-1442
Mailing Address - Country:US
Mailing Address - Phone:509-866-6846
Mailing Address - Fax:
Practice Address - Street 1:2397B HIGHWAY 141
Practice Address - Street 2:
Practice Address - City:TROUT LAKE
Practice Address - State:WA
Practice Address - Zip Code:98650-9735
Practice Address - Country:US
Practice Address - Phone:509-866-6846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR11344101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health