Basic Information
| Provider Information | |||||||||
| NPI: | 1699302380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREAU | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2016 RAINBOW LN | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144859453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854020140 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1045 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132032730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154251004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2020 | ||||||||
| LastUpdateDate: | 03/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 010350 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.