Healthcare Provider Details

I. General information

NPI: 1528868874
Provider Name (Legal Business Name): JONATHAN BREKKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1963 4TH AVE
SAN DIEGO CA
92101-2394
US

IV. Provider business mailing address

1963 4TH AVE
SAN DIEGO CA
92101-2394
US

V. Phone/Fax

Practice location:
  • Phone: 619-233-3432
  • Fax:
Mailing address:
  • Phone: 619-233-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number23086
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: