Provider Demographics
NPI:1386383388
Name:BRANUM, JACOB ANDREW
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:BRANUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 BRENMAN PARK DR APT 315
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7799
Mailing Address - Country:US
Mailing Address - Phone:571-550-0822
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD STE 600
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4389
Practice Address - Country:US
Practice Address - Phone:877-504-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician