Provider Demographics
NPI:1588235808
Name:BRACK, JADE (MSW, LISW)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:BRACK
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 RAEBURN TER
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45223-1231
Mailing Address - Country:US
Mailing Address - Phone:812-241-5384
Mailing Address - Fax:
Practice Address - Street 1:6881 BEECHMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-2907
Practice Address - Country:US
Practice Address - Phone:513-231-6630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.19019841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty