Provider Demographics
NPI:1558578070
Name:MIDDLEBROOKS, JAYNE THENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:JAYNE
Middle Name:THENISE
Last Name:MIDDLEBROOKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 VALOR RIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4838
Mailing Address - Country:US
Mailing Address - Phone:404-543-0758
Mailing Address - Fax:
Practice Address - Street 1:1652 VALOR RIDGE DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4838
Practice Address - Country:US
Practice Address - Phone:404-543-0758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050965174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist