1447493200 NPI number — MS. JENNE K BRDLIK LMSW

Table of content: MS. JENNE K BRDLIK LMSW (NPI 1447493200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447493200 NPI number — MS. JENNE K BRDLIK LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRDLIK
Provider First Name:
JENNE
Provider Middle Name:
K
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447493200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 579
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOHNS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85936-0579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-333-2683
Provider Business Mailing Address Fax Number:
928-333-5595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
470 WEST CLEVELAND
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOHNS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85936-0579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-337-4301
Provider Business Practice Location Address Fax Number:
928-337-2269
Provider Enumeration Date:
04/09/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LMSW-12616 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)