Provider Demographics
NPI:1447918040
Name:BROOKS, JEANA MARIE
Entity type:Individual
Prefix:
First Name:JEANA
Middle Name:MARIE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 NOLAN TRACE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446
Mailing Address - Country:US
Mailing Address - Phone:337-404-7731
Mailing Address - Fax:
Practice Address - Street 1:112 NOLAN TRACE
Practice Address - Street 2:SUITE B
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446
Practice Address - Country:US
Practice Address - Phone:337-404-7731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA171M00000XMedicaid