Provider Demographics
NPI:1235412735
Name:BRAKE, JESSICA L (MS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BRAKE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 1756
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0420
Mailing Address - Country:US
Mailing Address - Phone:541-670-2264
Mailing Address - Fax:
Practice Address - Street 1:2233 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2550
Practice Address - Country:US
Practice Address - Phone:541-670-2264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3280101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional