Healthcare Provider Details

I. General information

NPI: 1184144123
Provider Name (Legal Business Name): JONETTA BRACKEN LCSW CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3173 W SEXTON ST
SPRINGFIELD MO
65810-1297
US

IV. Provider business mailing address

1655 N MAYFAIR RD
MILWAUKEE WI
53226-3076
US

V. Phone/Fax

Practice location:
  • Phone: 262-402-2494
  • Fax:
Mailing address:
  • Phone: 262-402-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801120163
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2024047972
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8676-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: