Provider Demographics
NPI:1093450496
Name:BRANDENBURG, JERRICA LEE (LPCA, CADC)
Entity Type:Individual
Prefix:
First Name:JERRICA
Middle Name:LEE
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:LPCA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1281
Mailing Address - Country:US
Mailing Address - Phone:859-779-1492
Mailing Address - Fax:
Practice Address - Street 1:60 MERCY CT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1331
Practice Address - Country:US
Practice Address - Phone:859-779-1492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246646101YA0400X
KY275000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)