Provider Demographics
NPI:1518683382
Name:KENNON-LUJAN, BREANNA MICHELLE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MICHELLE
Last Name:KENNON-LUJAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 RUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2498
Mailing Address - Country:US
Mailing Address - Phone:951-955-8000
Mailing Address - Fax:
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-955-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104702104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty