Provider Demographics
NPI:1114350964
Name:FARMER-BRACKETT, JENNA (MA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:FARMER-BRACKETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:FARMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:221 E COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-3190
Mailing Address - Country:US
Mailing Address - Phone:618-639-2010
Mailing Address - Fax:618-639-2015
Practice Address - Street 1:221 E COUNTY RD
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-3190
Practice Address - Country:US
Practice Address - Phone:618-639-2010
Practice Address - Fax:618-639-2015
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional