Provider Demographics
NPI:1699245514
Name:JACOBS, BROOKE REGINA (PSYD)
Entity type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:REGINA
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5485 LOWER SALEM CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:GRAND CHAIN
Mailing Address - State:IL
Mailing Address - Zip Code:62941-2003
Mailing Address - Country:US
Mailing Address - Phone:618-771-6495
Mailing Address - Fax:
Practice Address - Street 1:548 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4538
Practice Address - Country:US
Practice Address - Phone:270-442-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2022-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010824103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical