MEDICARE: MRS. JACQUELINE DENISE BREWER LMSW, CAC II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1503	GA
2	104100000X	Social Worker	MSW003033	GA

General Provider Information

NPI Number	:	1285626085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELINE DENISE BREWER LMSW, CAC II

Provider Business Mailing Address
First Line	:	1061 HARMON AVE
Second Line	:	STE 1D03
City	:	FORT STEWART
State	:	GA
Zip	:	31314-5674
Country	:	US
Telephone Number	:	912-767-5265
Fax Number	:

Provider Business Practice Location Address
First Line	:	1061 HARMON AVE
Second Line	:	STE 1D03
City	:	FORT STEWART
State	:	GA
Zip	:	31314-5674
Country	:	US
Telephone Number	:	912-767-5265
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	05/03/2011

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