Provider Demographics
NPI:1982622866
Name:JAFFE, BRENDA H G (LCSW-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:H G
Last Name:JAFFE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 835
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-0835
Mailing Address - Country:US
Mailing Address - Phone:302-242-1028
Mailing Address - Fax:410-497-1104
Practice Address - Street 1:100 BOURBON ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3147
Practice Address - Country:US
Practice Address - Phone:410-939-9339
Practice Address - Fax:410-497-1104
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00002491041C0700X
MD134821041C0700X
NMI-075101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD150403701Medicaid