Provider Demographics
NPI:1487626529
Name:BREITBACH, JILL EFTA (PSY D)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:EFTA
Last Name:BREITBACH
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 W. SUNSET AVE
Mailing Address - Street 2:STE 15
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8366
Mailing Address - Country:US
Mailing Address - Phone:208-666-0357
Mailing Address - Fax:208-666-0468
Practice Address - Street 1:296 W. SUNSET AVE
Practice Address - Street 2:STE 15
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8366
Practice Address - Country:US
Practice Address - Phone:208-666-0357
Practice Address - Fax:208-666-0468
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical