Healthcare Provider Details

I. General information

NPI: 1497205306
Provider Name (Legal Business Name): JENNA BRACCO LICENSED CLINICAL SO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date: 04/17/2017
Reactivation Date: 03/26/2019

III. Provider practice location address

1274 W. 7TH AVENUE SUITE 201
EUGENE OR
97402
US

IV. Provider business mailing address

1274 W. 7TH AVENUE SUITE 201
EUGENE OR
97402
US

V. Phone/Fax

Practice location:
  • Phone: 804-405-8452
  • Fax:
Mailing address:
  • Phone: 804-405-8452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7048
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: