Provider Demographics
NPI:1457805806
Name:BRAA, JACLYN MARIE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:BRAA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MARIE
Other - Last Name:BUTTERMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2304 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-2318
Mailing Address - Country:US
Mailing Address - Phone:712-898-6602
Mailing Address - Fax:
Practice Address - Street 1:2304 E 17TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-2318
Practice Address - Country:US
Practice Address - Phone:712-898-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD78404-0103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool