=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457092447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARA JORDEN BRENNER RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2022
-----------------------------------------------------
Last Update Date | 04/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 E BRIDGE ST STE D
-----------------------------------------------------
City | WETUMPKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36092-2734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-782-5565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 BIRCHWOOD LN
-----------------------------------------------------
City | WETUMPKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36093-1776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-995-5229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | STUDENT
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN61044061
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------