Provider Demographics
NPI:1053994673
Name:JONES, BREANNA K
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:K
Last Name:JONES
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 1:7924 MOBILE AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-1856
Mailing Address - Country:US
Mailing Address - Phone:773-319-2379
Mailing Address - Fax:
Practice Address - Street 1:11200 WAPLES MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7475
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:703-237-2729
Is Sole Proprietor?:No
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-21-155828106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician