Provider Demographics
NPI:1578528451
Name:BROOKS, JENNIFER C (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:C
Last Name:BROOKS
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 1:909 9TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3903
Mailing Address - Country:US
Mailing Address - Phone:817-334-0562
Mailing Address - Fax:817-335-4328
Practice Address - Street 1:909 9TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3903
Practice Address - Country:US
Practice Address - Phone:817-334-0562
Practice Address - Fax:817-335-4328
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7394174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF24693Medicare UPIN