Provider Demographics
NPI:1710606900
Name:SMITH-BRAKE, JESSICA LEIGH
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:SMITH-BRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:624 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:BRONSTON
Mailing Address - State:KY
Mailing Address - Zip Code:42518-9526
Mailing Address - Country:US
Mailing Address - Phone:606-307-0036
Mailing Address - Fax:
Practice Address - Street 1:200 TOWER CIR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3480
Practice Address - Country:US
Practice Address - Phone:606-416-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst