Provider Demographics
NPI:1982827879
Name:BREUER, JACKIE LYNNE (LMF)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LYNNE
Last Name:BREUER
Suffix:
Gender:F
Credentials:LMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7747 MITCHELL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4725
Mailing Address - Country:US
Mailing Address - Phone:661-433-6382
Mailing Address - Fax:
Practice Address - Street 1:7747 MITCHELL BLVD STE B
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4725
Practice Address - Country:US
Practice Address - Phone:661-433-6382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46070106H00000X
FLMT2656106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007473Medicaid
CACBSC144OtherLA DMH PROVIDER