Provider Demographics
NPI:1679865711
Name:BROOKS, JENNIFER LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 W MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-8217
Mailing Address - Country:US
Mailing Address - Phone:518-743-1105
Mailing Address - Fax:
Practice Address - Street 1:15 QUADE ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-2724
Practice Address - Country:US
Practice Address - Phone:518-792-1451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005547-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant