Provider Demographics
NPI:1659003168
Name:BRENNAN, JACQUELAINE DOROTHY
Entity Type:Individual
Prefix:
First Name:JACQUELAINE
Middle Name:DOROTHY
Last Name:BRENNAN
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 1:21275 W VISTA ROYALE DR
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-1285
Mailing Address - Country:US
Mailing Address - Phone:623-853-3789
Mailing Address - Fax:
Practice Address - Street 1:21275 W VISTA ROYALE DR
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1285
Practice Address - Country:US
Practice Address - Phone:623-853-3789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2753172084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry