Provider Demographics
NPI:1255493573
Name:BROOKS, JODENE (PHD)
Entity Type:Individual
Prefix:
First Name:JODENE
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 SHADES CREEK PKWY
Mailing Address - Street 2:SUITE 202A
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-4542
Mailing Address - Country:US
Mailing Address - Phone:205-870-5678
Mailing Address - Fax:
Practice Address - Street 1:813 SHADES CREEK PKWY
Practice Address - Street 2:SUITE 202A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-4542
Practice Address - Country:US
Practice Address - Phone:205-870-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL680103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000074714Medicaid
AL510-74714OtherBCBS
AL000073932Medicaid
AL515-93052OtherFEDERAL BC
AL510-73932OtherBCBS
AL1255493573OtherTRICARE SOUTH