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General NPI Number Information
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NPI Number | 1114039880
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Entity Type | Individual
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Provider Name | JACK C. BRANDON LMSM
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Gender | Male
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 05/09/2024
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Provider Practice Location Address
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Address Line | 1601 SW ARCHER RD
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City | GAINESVILLE
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State | FL
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Zip | 32608-1135
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Country | US
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Telephone | 352-376-1611
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Fax |
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Provider Business Mailing Address
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Address Line | 491 ALTON AVE
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City | BATTLE CREEK
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State | MI
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Zip | 49017-3211
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Country | US
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Telephone | 269-268-3280
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801067748
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License Number State | MI
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