Provider Demographics
NPI:1023268240
Name:BROOKS, JENNIFER LYNNE (PAC)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNNE
Other - Last Name:ATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1801 N 6TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-4097
Mailing Address - Country:US
Mailing Address - Phone:812-235-4867
Mailing Address - Fax:812-232-8059
Practice Address - Street 1:1801 N 6TH ST STE 600
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4097
Practice Address - Country:US
Practice Address - Phone:812-235-4867
Practice Address - Fax:812-232-8059
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003316363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
940939OtherHEALTHLINK
153063OtherHEALTH ALLIANCE
IL294490004Medicare PIN