Provider Demographics
NPI:1548772965
Name:BREITENBACH, JENNIFER MAE LAVENE (CDCA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAE LAVENE
Last Name:BREITENBACH
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-0226
Mailing Address - Country:US
Mailing Address - Phone:740-493-4260
Mailing Address - Fax:740-493-4262
Practice Address - Street 1:15221 STATE ROUTE 772
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-9062
Practice Address - Country:US
Practice Address - Phone:740-493-4260
Practice Address - Fax:740-493-4262
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162885101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)