Basic Information
| Provider Information | |||||||||
| NPI: | 1083229751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRANAM | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 SOUTH EDWIN C MOSES BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454173424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377348333 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.422570 | OH | N | Nursing Service Providers | Registered Nurse | 363LP0808X | APRN.CNP.0028292 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0435665 | 05 | OH | MEDICAID | MB6280173 | 01 | DEA | OTHER |