Provider Demographics
NPI:1013268911
Name:BRENNEKE, JANE SUSANN (MS, LPC)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:SUSANN
Last Name:BRENNEKE
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9928 THURMAN OAKS RD
Mailing Address - Street 2:
Mailing Address - City:VALLES MINES
Mailing Address - State:MO
Mailing Address - Zip Code:63087-1324
Mailing Address - Country:US
Mailing Address - Phone:636-249-9993
Mailing Address - Fax:636-243-3903
Practice Address - Street 1:12312 HIGHWAY 21
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-3221
Practice Address - Country:US
Practice Address - Phone:636-249-9993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012024498101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1013268911Medicaid