Basic Information
| Provider Information | |||||||||
| NPI: | 1902225030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 HARBOR HILLS DR STE C | ||||||||
| Address2: | |||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062255458 | ||||||||
| FaxNumber: | 9062251179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 71818-20 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | 4301113739 | MI | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 4301113739 | MI | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.