Provider Demographics
NPI:1144758871
Name:GATES-BREEN, JENNIFER JEANNE (MS, CCC-SLP, BCS-S)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEANNE
Last Name:GATES-BREEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP, BCS-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15764 S AVENUE 5 E
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-8012
Mailing Address - Country:US
Mailing Address - Phone:928-210-1577
Mailing Address - Fax:928-336-7473
Practice Address - Street 1:2851 S AVENUE B STE 2504
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7758
Practice Address - Country:US
Practice Address - Phone:928-336-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist