Provider Demographics
NPI:1740322429
Name:JILLIAN BROOKS
Entity type:Organization
Organization Name:JILLIAN BROOKS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/TECHNOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:CRT
Authorized Official - Phone:530-824-9433
Mailing Address - Street 1:1220 ALMOND AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-1308
Mailing Address - Country:US
Mailing Address - Phone:530-824-9433
Mailing Address - Fax:530-824-9497
Practice Address - Street 1:155 SOLANO ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:CA
Practice Address - Zip Code:96021-3511
Practice Address - Country:US
Practice Address - Phone:530-824-9433
Practice Address - Fax:530-824-9497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01732261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIDTF00170Medicaid
ZZZ6103012OtherBLUE SHIELD
ZZZ6103012OtherBLUE SHIELD
ZZZ15603ZMedicare ID - Type Unspecified