Provider Demographics
NPI:1922894765
Name:JENNISON, BREAUNA MAE
Entity type:Individual
Prefix:
First Name:BREAUNA
Middle Name:MAE
Last Name:JENNISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507 JACOB ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-1892
Mailing Address - Country:US
Mailing Address - Phone:304-650-6098
Mailing Address - Fax:
Practice Address - Street 1:4507 JACOB ST APT 2
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-1892
Practice Address - Country:US
Practice Address - Phone:304-650-6098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1356607394Medicaid
WV1821206228Medicaid