Provider Demographics
NPI:1881909224
Name:BROOK, JILL (PHD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BROOK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:NJ
Mailing Address - Zip Code:07934-0542
Mailing Address - Country:US
Mailing Address - Phone:908-719-7555
Mailing Address - Fax:908-719-7523
Practice Address - Street 1:205 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:NJ
Practice Address - Zip Code:07934-2059
Practice Address - Country:US
Practice Address - Phone:908-719-7555
Practice Address - Fax:908-719-7523
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00290300103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist