MEDICARE: JENNA BRACKETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		MI

General Provider Information

NPI Number	:	1265826069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA BRACKETT

Provider Business Mailing Address
First Line	:	901 EASTERN AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1201
Country	:	US
Telephone Number	:	616-224-7429
Fax Number	:	616-574-7966

Provider Business Practice Location Address
First Line	:	211 TROWBRIDGE ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1552
Country	:	US
Telephone Number	:	517-740-1978
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2015
Last Update Date	:	04/23/2019

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Directions to “ JENNA BRACKETT ” Practice Location

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