Provider Demographics
NPI:1952789638
Name:GERLACH, BROOKE JACKSON (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:JACKSON
Last Name:GERLACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ELISABETH
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1038 SALTWATER CIRCLE
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455
Mailing Address - Country:US
Mailing Address - Phone:864-790-0500
Mailing Address - Fax:
Practice Address - Street 1:1818 REMANT RD
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410
Practice Address - Country:US
Practice Address - Phone:843-410-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLRD.1256133V00000X
SC3074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered