Provider Demographics
NPI:1578175253
Name:BRAKHAGE, JEFFREY DANIEL (LPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DANIEL
Last Name:BRAKHAGE
Suffix:
Gender:M
Credentials:LPC
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 3222
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-3222
Mailing Address - Country:US
Mailing Address - Phone:907-671-6737
Mailing Address - Fax:
Practice Address - Street 1:35477 KENAI SPUR HWY STE 214
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7642
Practice Address - Country:US
Practice Address - Phone:907-671-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-23
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK155471101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1578175253Medicaid