Provider Demographics
NPI:1356977748
Name:BRANTLEY, JANNETTE D (LMCH)
Entity type:Individual
Prefix:MRS
First Name:JANNETTE
Middle Name:D
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:LMCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 N PEARL ST STE C1
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2490
Mailing Address - Country:US
Mailing Address - Phone:253-752-1860
Mailing Address - Fax:253-752-1890
Practice Address - Street 1:1919 N PEARL ST STE C1
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2490
Practice Address - Country:US
Practice Address - Phone:253-752-1860
Practice Address - Fax:253-752-1890
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61021335101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA604598103OtherUBI