Provider Demographics
NPI:1235635509
Name:BREWER, JASON WAYNE
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WAYNE
Last Name:BREWER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15770 MOJAVE DR STE L
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-1934
Mailing Address - Country:US
Mailing Address - Phone:760-843-7809
Mailing Address - Fax:
Practice Address - Street 1:15770 MOJAVE DR STE L
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1934
Practice Address - Country:US
Practice Address - Phone:760-843-7809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)