Provider Demographics
NPI:1265276521
Name:BRENNAN, JESSICA LARSEN (LMT, CD, LCCE)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LARSEN
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:LMT, CD, LCCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3045
Mailing Address - Country:US
Mailing Address - Phone:973-780-7759
Mailing Address - Fax:
Practice Address - Street 1:1285 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3045
Practice Address - Country:US
Practice Address - Phone:973-780-7759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth Educator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty