Provider Demographics
NPI:1750449534
Name:BROOKS, JENNIFER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
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 1:104 ANDREWS STREET
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601
Mailing Address - Country:US
Mailing Address - Phone:864-269-5766
Mailing Address - Fax:864-269-5767
Practice Address - Street 1:104 ANDREWS STREET
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601
Practice Address - Country:US
Practice Address - Phone:864-269-5766
Practice Address - Fax:864-269-5767
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4685101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCBT-019Medicaid