Provider Demographics
NPI:1700074721
Name:BRACKENBURY, JAMIE (RDH)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BRACKENBURY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9202 W GAGE BLVD APT R202
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7138
Mailing Address - Country:US
Mailing Address - Phone:208-412-9114
Mailing Address - Fax:
Practice Address - Street 1:9202 W GAGE BLVD APT R202
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7138
Practice Address - Country:US
Practice Address - Phone:208-412-9114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHL00007968124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist