Basic Information
| Provider Information | |||||||||
| NPI: | 1487152948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 875 OAK ST SE STE 5060 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033991386 | ||||||||
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| Practice Location | |||||||||
| Address1: | 875 OAK ST SE STE 5060 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033991386 | ||||||||
| FaxNumber: | 5033991182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2018 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.0005178 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA188460 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.