Provider Demographics
NPI:1750083739
Name:BRANTLEY, JACI CAROLYNN
Entity type:Individual
Prefix:
First Name:JACI
Middle Name:CAROLYNN
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACI
Other - Middle Name:CAROLYNN
Other - Last Name:BRANTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:622 RUTH CIR
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-5548
Mailing Address - Country:US
Mailing Address - Phone:414-940-5581
Mailing Address - Fax:
Practice Address - Street 1:622 RUTH CIR
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-5548
Practice Address - Country:US
Practice Address - Phone:414-940-5581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist