Provider Demographics
NPI:1609201896
Name:PAGE, BRIAN JESSE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JESSE
Last Name:PAGE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 MILITIA DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-1203
Mailing Address - Country:US
Mailing Address - Phone:573-638-2712
Mailing Address - Fax:573-638-9815
Practice Address - Street 1:2302 MILITIA DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-1203
Practice Address - Country:US
Practice Address - Phone:573-638-9500
Practice Address - Fax:573-638-9812
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080023151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical