Provider Demographics
NPI:1801940325
Name:BRANNON, JERRAY ANTHONY (BS QMHA)
Entity type:Individual
Prefix:
First Name:JERRAY
Middle Name:ANTHONY
Last Name:BRANNON
Suffix:
Gender:M
Credentials:BS QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 NE 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3343
Mailing Address - Country:US
Mailing Address - Phone:503-309-7071
Mailing Address - Fax:503-493-1635
Practice Address - Street 1:131 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4167
Practice Address - Country:US
Practice Address - Phone:503-253-6754
Practice Address - Fax:503-251-1344
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator