Provider Demographics
NPI:1972128932
Name:BROOKER, JESSILEE GABRIELLE (DMD)
Entity Type:Individual
Prefix:
First Name:JESSILEE
Middle Name:GABRIELLE
Last Name:BROOKER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 MADISON AVE N
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2802
Mailing Address - Country:US
Mailing Address - Phone:912-384-4432
Mailing Address - Fax:
Practice Address - Street 1:1108 MADISON AVE N
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2802
Practice Address - Country:US
Practice Address - Phone:912-384-4432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO16039122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist