Basic Information
Provider Information | |||||||||
NPI: | 1649370503 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRECHTEL | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 BROAD AVE | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395013603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288631132 | ||||||||
FaxNumber: | 2288651700 | ||||||||
Practice Location | |||||||||
Address1: | 1600 BROAD AVE | ||||||||
Address2: |   | ||||||||
City: | GULFPORT | ||||||||
State: | MS | ||||||||
PostalCode: | 395013603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2288631132 | ||||||||
FaxNumber: | 2288651700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 01/27/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | C6737 | MS | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 106H00000X | C6737 | MS | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 363LP0808X | R873301 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 02309788 | 05 | MS |   | MEDICAID |