Provider Demographics
NPI:1184827784
Name:BREWER, JACQUELYN MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:BREWER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 STRAWBERRY HILL COURT
Mailing Address - Street 2:EAR, NOSE, AND THROAT CENTER
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2594
Mailing Address - Country:US
Mailing Address - Phone:203-359-3533
Mailing Address - Fax:203-357-8109
Practice Address - Street 1:32 STRAWBERRY HILL COURT
Practice Address - Street 2:EAR, NOSE, AND THROAT CENTER
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2594
Practice Address - Country:US
Practice Address - Phone:203-359-3533
Practice Address - Fax:203-357-8109
Is Sole Proprietor?:No
Enumeration Date:2007-06-09
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT049534207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0026059OtherINSTITUTIONAL PERMIT