Provider Demographics
NPI:1760501084
Name:BRAINARD, JAE (LCSW)
Entity type:Individual
Prefix:MS
First Name:JAE
Middle Name:
Last Name:BRAINARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5214 WESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-1642
Mailing Address - Country:US
Mailing Address - Phone:919-481-0574
Mailing Address - Fax:919-851-3636
Practice Address - Street 1:5214 WESTERN BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-1642
Practice Address - Country:US
Practice Address - Phone:919-481-0574
Practice Address - Fax:919-851-3636
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0024621041C0700X
UT2212657835011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10607OtherBCBS