Healthcare Provider Details

I. General information

NPI: 1669811725
Provider Name (Legal Business Name): JASON CHARLES BROOKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 PERRY ST
NEWNAN GA
30263-1974
US

IV. Provider business mailing address

125 WILLIAMS ST 5C
CARROLLTON GA
30117-2274
US

V. Phone/Fax

Practice location:
  • Phone: 678-423-4610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: