Provider Demographics
NPI:1427426105
Name:JACK, BRANDI LEIGH (MA, LAC, LPCC)
Entity type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:LEIGH
Last Name:JACK
Suffix:
Gender:F
Credentials:MA, LAC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 DENVER AVE # 325
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-5226
Mailing Address - Country:US
Mailing Address - Phone:970-378-8805
Mailing Address - Fax:
Practice Address - Street 1:1601 25TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4907
Practice Address - Country:US
Practice Address - Phone:970-378-8805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0022539101YM0800X
COACD.0002625101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health