Healthcare Provider Details

I. General information

NPI: 1235793043
Provider Name (Legal Business Name): JACOB LEWIS BRENNAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

IV. Provider business mailing address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-6810
  • Fax: 210-450-6023
Mailing address:
  • Phone: 210-450-6810
  • Fax: 210-450-6023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberV7191
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: