Provider Demographics
NPI:1508968462
Name:BROOKS, JEFFREY (MA,LLPC,LAD,CAC-I)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MA,LLPC,LAD,CAC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2651
Mailing Address - Country:US
Mailing Address - Phone:248-547-2223
Mailing Address - Fax:
Practice Address - Street 1:150 W HILDALE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-1948
Practice Address - Country:US
Practice Address - Phone:313-893-5034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI620390564853101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI631090Medicaid