Provider Demographics
NPI:1356953053
Name:BRACKENRICH, JAMIE (FNP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BRACKENRICH
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LEIGH
Other - Last Name:SHRADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4521 BRAMBLETON AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3432
Mailing Address - Country:US
Mailing Address - Phone:540-312-0105
Mailing Address - Fax:855-592-1912
Practice Address - Street 1:4521 BRAMBLETON AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-2401
Practice Address - Country:US
Practice Address - Phone:540-315-4766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024179822OtherVIRGINIA BOARD OF NURSING