Provider Demographics
NPI:1922351188
Name:BREEBACK, JADE LEIGH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JADE
Middle Name:LEIGH
Last Name:BREEBACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 NC HIGHWAY 66 S
Mailing Address - Street 2:155
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-3854
Mailing Address - Country:US
Mailing Address - Phone:336-996-2006
Mailing Address - Fax:
Practice Address - Street 1:1635 NC HIGHWAY 66 S
Practice Address - Street 2:155
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3854
Practice Address - Country:US
Practice Address - Phone:336-996-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant