Healthcare Provider Details

I. General information

NPI: 1003905985
Provider Name (Legal Business Name): JACOB MICHAEL BRENING ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 NORTH OCOEE LEE UNIVERSITY ATHLETICS
CLEVELAND TN
37311
US

IV. Provider business mailing address

2191 OLD HARRISON PIKE NW APT 2
CLEVELAND TN
37311-1098
US

V. Phone/Fax

Practice location:
  • Phone: 423-614-8527
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0000000990
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: