Provider Demographics
NPI:1316160807
Name:BRACKEN MENTAL HEALTH A PROFESSIONAL ASSOCIATION.
Entity type:Organization
Organization Name:BRACKEN MENTAL HEALTH A PROFESSIONAL ASSOCIATION.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-278-5385
Mailing Address - Street 1:3200 SOUTHERN DR
Mailing Address - Street 2:#107
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1549
Mailing Address - Country:US
Mailing Address - Phone:972-278-5385
Mailing Address - Fax:972-692-8687
Practice Address - Street 1:3200 SOUTHERN DR
Practice Address - Street 2:#107
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-1549
Practice Address - Country:US
Practice Address - Phone:972-278-5385
Practice Address - Fax:972-692-8687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK69922084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113612904Medicaid
TX=========OtherEIN
TX=========OtherEIN