Provider Demographics
NPI:1386221430
Name:JERNIGAN, BROOKE ALSTON (LCSW)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALSTON
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 BRAMLETT RD
Mailing Address - Street 2:
Mailing Address - City:MONETA
Mailing Address - State:VA
Mailing Address - Zip Code:24121-6246
Mailing Address - Country:US
Mailing Address - Phone:540-525-0908
Mailing Address - Fax:540-215-7226
Practice Address - Street 1:302 WASHINGTON AVE SW STE B
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4312
Practice Address - Country:US
Practice Address - Phone:540-524-9918
Practice Address - Fax:540-215-7226
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040127521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA601518555Medicaid