Provider Demographics
NPI:1245870450
Name:BRAENDEHOLM, JENNIFER CONSTANCE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CONSTANCE
Last Name:BRAENDEHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E PRATT ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-3116
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:400 E PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-3116
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA739103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1700024296Medicaid
MD1700024296OtherTRI CARE HUMANA