Provider Demographics
NPI:1316629975
Name:BRANDT, JAYNE EVELYN
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:EVELYN
Last Name:BRANDT
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 1:11475 HIGHWAY 99E
Mailing Address - Street 2:
Mailing Address - City:LOS MOLINOS
Mailing Address - State:CA
Mailing Address - Zip Code:96055-9631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7592 METROPOLITAN DR STE 404
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4428
Practice Address - Country:US
Practice Address - Phone:619-376-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-23-283410106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician