Healthcare Provider Details

I. General information

NPI: 1255577755
Provider Name (Legal Business Name): MRS. JENNIFER SUE BROOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 COUNTY ROAD 15
MARENGO OH
43334-9619
US

IV. Provider business mailing address

5151 COUNTY ROAD 15
MARENGO OH
43334-9619
US

V. Phone/Fax

Practice location:
  • Phone: 740-501-3582
  • Fax:
Mailing address:
  • Phone: 740-501-3582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN 128383
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA006638
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: