Provider Demographics
NPI:1710053319
Name:BRACKEN, JILL W (DO)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:W
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 SOUTHERN DR STE 107
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1549
Mailing Address - Country:US
Mailing Address - Phone:972-278-5385
Mailing Address - Fax:972-692-8687
Practice Address - Street 1:3200 SOUTHERN DR STE 107
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-1549
Practice Address - Country:US
Practice Address - Phone:972-278-5385
Practice Address - Fax:972-692-8687
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK69922084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8250J4Medicare PIN
TX8F0907Medicare PIN