Provider Demographics
NPI:1598972051
Name:BRUNER, JENNIFER RAE (MA, ATR-BC, NCC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:BRUNER
Suffix:
Gender:F
Credentials:MA, ATR-BC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 TUXEDO BLVD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2044
Mailing Address - Country:US
Mailing Address - Phone:314-963-3264
Mailing Address - Fax:
Practice Address - Street 1:2510 S BRENTWOOD BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-2328
Practice Address - Country:US
Practice Address - Phone:314-467-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-005288101YP2500X
221700000X
MO2007014463101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist