Provider Demographics
NPI:1255807210
Name:SJOSTROM, BROOKE EARIN (MS)
Entity type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:EARIN
Last Name:SJOSTROM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BROOKE
Other - Last Name:SJOSTROM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0129
Mailing Address - Country:US
Mailing Address - Phone:208-691-1174
Mailing Address - Fax:208-247-8513
Practice Address - Street 1:250 NORTHWEST BLVD STE 101A
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2971
Practice Address - Country:US
Practice Address - Phone:208-691-1174
Practice Address - Fax:208-247-8513
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007832101YM0800X
IDLCPC-4347101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health