Provider Demographics
NPI:1326597519
Name:OPTIMAL HEALTH MANAGEMENT
Entity Type:Organization
Organization Name:OPTIMAL HEALTH MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:541-670-2264
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:GLIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97443-0608
Mailing Address - Country:US
Mailing Address - Phone:541-670-2264
Mailing Address - Fax:866-298-7465
Practice Address - Street 1:753 SE MAIN ST
Practice Address - Street 2:#204, 205, 212
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3938
Practice Address - Country:US
Practice Address - Phone:541-670-2264
Practice Address - Fax:866-298-7465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3280101YM0800X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty