Provider Demographics
NPI:1730281510
Name:BRUSTER, JENNETTE ILENE (MA LPC)
Entity Type:Individual
Prefix:MISS
First Name:JENNETTE
Middle Name:ILENE
Last Name:BRUSTER
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-5611
Mailing Address - Country:US
Mailing Address - Phone:864-455-4828
Mailing Address - Fax:864-455-1710
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-4828
Practice Address - Fax:864-455-1710
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4906101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC3333Medicare ID - Type Unspecified