Healthcare Provider Details

I. General information

NPI: 1003290693
Provider Name (Legal Business Name): JESSE BROUWER PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11081 FOREST PINES DR STE 112
RALEIGH NC
27614-7656
US

IV. Provider business mailing address

11081 FOREST PINES DR STE 112
RALEIGH NC
27614-7656
US

V. Phone/Fax

Practice location:
  • Phone: 919-562-9410
  • Fax: 919-562-9425
Mailing address:
  • Phone: 919-562-9410
  • Fax: 919-562-9425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP22359
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: