Provider Demographics
NPI:1689146268
Name:BRECKENRIDGE, JAMAICA ERICA
Entity type:Individual
Prefix:
First Name:JAMAICA
Middle Name:ERICA
Last Name:BRECKENRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMAICA
Other - Middle Name:
Other - Last Name:LEFLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:HC 63 BOX 270161
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84027-2702
Mailing Address - Country:US
Mailing Address - Phone:435-503-5582
Mailing Address - Fax:
Practice Address - Street 1:13947 S NEWBURG DR
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-6787
Practice Address - Country:US
Practice Address - Phone:385-248-2081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker