Healthcare Provider Details

I. General information

NPI: 1932037397
Provider Name (Legal Business Name): JACOB DAVID BROCKERT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43097 WOODWARD AVE STE 102
BLOOMFIELD TOWNSHIP MI
48302-5042
US

IV. Provider business mailing address

44670 ANN ARBOR RD W STE 130
PLYMOUTH MI
48170-4085
US

V. Phone/Fax

Practice location:
  • Phone: 313-278-4601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501304352
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: