Provider Demographics
NPI:1336612761
Name:BRANNAN, JAMIE LYNN (RBT)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LYNN
Last Name:BRANNAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:WEWAHITCHKA
Mailing Address - State:FL
Mailing Address - Zip Code:32465-7646
Mailing Address - Country:US
Mailing Address - Phone:850-227-5759
Mailing Address - Fax:
Practice Address - Street 1:528 CECIL G COSTIN SR BLVD STE A
Practice Address - Street 2:
Practice Address - City:PORT SAINT JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1754
Practice Address - Country:US
Practice Address - Phone:850-229-2756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-46015106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty