Provider Demographics
NPI:1548313562
Name:BREAKSTONE, JERRY (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:BREAKSTONE
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3027
Mailing Address - Country:US
Mailing Address - Phone:314-398-0453
Mailing Address - Fax:
Practice Address - Street 1:7396 PERSHING AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-4206
Practice Address - Country:US
Practice Address - Phone:314-398-0453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0048681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical