Provider Demographics
NPI:1255802369
Name:BREWER, JACKIE TRIMBLE (RBT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:TRIMBLE
Last Name:BREWER
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 SAMMONS RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-6916
Mailing Address - Country:US
Mailing Address - Phone:606-205-3261
Mailing Address - Fax:
Practice Address - Street 1:10 6TH AVE W
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-0028
Practice Address - Country:US
Practice Address - Phone:304-825-8014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRBT-18-67317106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician