Provider Demographics
NPI:1194950576
Name:BRAZIEL, JACLYN RENEE (QMHP)
Entity type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:RENEE
Last Name:BRAZIEL
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:RENEE
Other - Last Name:BRANSKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2205 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-9742
Mailing Address - Country:US
Mailing Address - Phone:503-930-7349
Mailing Address - Fax:
Practice Address - Street 1:182 SW ACADEMY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1996
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4153101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health