Healthcare Provider Details

I. General information

NPI: 1275063364
Provider Name (Legal Business Name): JANE BROOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE MCCONNELL

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7510 MONTGOMERY BLVD NE STE 202
ALBUQUERQUE NM
87109-1500
US

IV. Provider business mailing address

7520 MONTGOMERY BLVD NE BLDG E15
ALBUQUERQUE NM
87109-1586
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-6355
  • Fax: 505-214-5852
Mailing address:
  • Phone: 505-226-6380
  • Fax: 505-214-5852

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: