Provider Demographics
NPI:1184397416
Name:JACKSON, BROOKE WARE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:WARE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 BRAMBLETON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3658
Mailing Address - Country:US
Mailing Address - Phone:540-725-7800
Mailing Address - Fax:
Practice Address - Street 1:3707 BRAMBLETON AVE STE 2
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3658
Practice Address - Country:US
Practice Address - Phone:540-725-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily