1386221430 NPI number — BROOKE ALSTON JERNIGAN LCSW

Table of content: BROOKE ALSTON JERNIGAN LCSW (NPI 1386221430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386221430 NPI number — BROOKE ALSTON JERNIGAN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERNIGAN
Provider First Name:
BROOKE
Provider Middle Name:
ALSTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386221430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 BRAMLETT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONETA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24121-6246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-525-0908
Provider Business Mailing Address Fax Number:
540-215-7226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 WASHINGTON AVE SW STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24016-4312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-524-9918
Provider Business Practice Location Address Fax Number:
540-215-7226
Provider Enumeration Date:
03/25/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904012752 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 601518555 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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