Healthcare Provider Details

I. General information

NPI: 1265988349
Provider Name (Legal Business Name): JORDAN LEE BROOKS MS MHCA SUDP CPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 ALLEN ST
KELSO WA
98626-4907
US

IV. Provider business mailing address

1116 14TH AVE
LONGVIEW WA
98632-3017
US

V. Phone/Fax

Practice location:
  • Phone: 602-617-0203
  • Fax:
Mailing address:
  • Phone: 360-261-6930
  • Fax: 360-748-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMC61475302
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC61475302
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60848399
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: