Healthcare Provider Details

I. General information

NPI: 1871571232
Provider Name (Legal Business Name): BRECK JON LEBEGUE MD MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S J ST
TACOMA WA
98405-4933
US

IV. Provider business mailing address

2200 BERGQUIST DR ATTN: CREDENTIALS (CMC)
LACKLAND A F B TX
78236-9908
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-6691
  • Fax: 253-426-6492
Mailing address:
  • Phone: 210-292-6707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number159944-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD60527976
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: