Healthcare Provider Details

I. General information

NPI: 1821337031
Provider Name (Legal Business Name): JACOB G BRUECK PT, DPT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 E 1ST ST
ANKENY IA
50021-2007
US

IV. Provider business mailing address

710 E 1ST ST
ANKENY IA
50021-2007
US

V. Phone/Fax

Practice location:
  • Phone: 515-965-5311
  • Fax: 515-965-5301
Mailing address:
  • Phone: 515-965-5311
  • Fax: 515-965-5301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005080
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1231180
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: