Provider Demographics
NPI:1710450606
Name:BRUER-VANDEWEERT, JENNIFER ELAYNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAYNE
Last Name:BRUER-VANDEWEERT
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 1:10 HILTON RD
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053-9709
Mailing Address - Country:US
Mailing Address - Phone:607-227-6340
Mailing Address - Fax:
Practice Address - Street 1:10 HILTON RD
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053-9709
Practice Address - Country:US
Practice Address - Phone:607-227-6340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9429225100000X
TX1313495225100000X
NC18459225100000X
FL34271225100000X
NY043748225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist