Provider Demographics
NPI:1629709951
Name:BRACKEN, JESSICA LYNN (BCBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 S DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1618
Mailing Address - Country:US
Mailing Address - Phone:715-797-8902
Mailing Address - Fax:
Practice Address - Street 1:1011 MEADOWLANDS DR
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-2339
Practice Address - Country:US
Practice Address - Phone:612-315-1976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WI1007140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst