Basic Information
| Provider Information | |||||||||
| NPI: | 1649895954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRECKENRIDGE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 743 E 1060 S | ||||||||
| Address2: | |||||||||
| City: | SPRINGVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846632867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014721082 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 750 N FREEDOM BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846011677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4760801373 | ||||||||
| FaxNumber: | 8013730639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2020 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 104100000X | 12308109-3506 | UT | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.