Provider Demographics
NPI:1205369436
Name:BRAKEMAN, JENNIFER DAWN (LM)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:BRAKEMAN
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0265
Mailing Address - Country:US
Mailing Address - Phone:208-699-5261
Mailing Address - Fax:
Practice Address - Street 1:1076 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835
Practice Address - Country:US
Practice Address - Phone:208-772-2823
Practice Address - Fax:208-209-3120
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMID-57176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife