Provider Demographics
NPI:1760785521
Name:BRENDA JAFFE, LCSW-C, LLC
Entity Type:Organization
Organization Name:BRENDA JAFFE, LCSW-C, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:HG
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:302-242-1028
Mailing Address - Street 1:PO BOX 835
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-0835
Mailing Address - Country:US
Mailing Address - Phone:302-242-1028
Mailing Address - Fax:410-497-1104
Practice Address - Street 1:100 BOURBON ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3147
Practice Address - Country:US
Practice Address - Phone:410-939-9339
Practice Address - Fax:410-497-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13482251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD15O4O3701Medicaid