Provider Demographics
NPI:1447520374
Name:BROOKS, JENNIFER ELLYN (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ELLYN
Last Name:BROOKS
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 1:1576 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8616
Mailing Address - Country:US
Mailing Address - Phone:850-478-3888
Mailing Address - Fax:
Practice Address - Street 1:1576 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8616
Practice Address - Country:US
Practice Address - Phone:850-478-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2981-57103TC0700X
FLPY8972103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHT204AMedicare PIN