Provider Demographics
NPI:1669679619
Name:HAWTHORNE, JENNIFER BRUCKMAN (MA, PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BRUCKMAN
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8440 REA ROAD
Mailing Address - Street 2:SUITE M
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6711
Mailing Address - Country:US
Mailing Address - Phone:704-608-8091
Mailing Address - Fax:
Practice Address - Street 1:8440 REA ROAD
Practice Address - Street 2:SUITE M
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6711
Practice Address - Country:US
Practice Address - Phone:704-608-8091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3582103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical