Basic Information
| Provider Information | |||||||||
| NPI: | 1659965648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNER | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | ALLYSSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13481 W MCDOWELL RD STE 300 | ||||||||
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| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853952720 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1190 E MISSOURI AVE STE 100 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850142719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023930520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2021 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.