Provider Demographics
NPI:1124440052
Name:BROOKS, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:6340 WASHINGTON ST NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4880 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:HILLTOP
Practice Address - State:MN
Practice Address - Zip Code:55421-1950
Practice Address - Country:US
Practice Address - Phone:763-571-7195
Practice Address - Fax:763-571-9340
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-12
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist