Provider Demographics
NPI:1316526130
Name:BROOKS, REGGIE SR
Entity type:Individual
Prefix:MR
First Name:REGGIE
Middle Name:
Last Name:BROOKS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10979 APPLE BLOSSOM TRL E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7358
Mailing Address - Country:US
Mailing Address - Phone:240-277-7255
Mailing Address - Fax:
Practice Address - Street 1:2392 EDGEWOOD AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1725
Practice Address - Country:US
Practice Address - Phone:904-781-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator