Provider Demographics
NPI:1588108922
Name:GARDNER BROOKS, JENEAN ALESHA
Entity type:Individual
Prefix:
First Name:JENEAN
Middle Name:ALESHA
Last Name:GARDNER 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 1:1950 BRIDGESTONE CIR
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3793
Mailing Address - Country:US
Mailing Address - Phone:678-770-2470
Mailing Address - Fax:
Practice Address - Street 1:2945 PANOLA RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2313
Practice Address - Country:US
Practice Address - Phone:678-732-1518
Practice Address - Fax:404-614-7358
Is Sole Proprietor?:No
Enumeration Date:2016-12-04
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN202341363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily