MEDICARE: JACOB THOMAS BROWNBACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	2012021520	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2000010702	OTHER		NATA BOARD OF CERTIFICATION

General Provider Information

NPI Number	:	1154757078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB THOMAS BROWNBACK

Provider Business Mailing Address
First Line	:	4628 LAFAYETTE AVE
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-3335
Country	:	US
Telephone Number	:	913-302-9317
Fax Number	:

Provider Business Practice Location Address
First Line	:	4628 LAFAYETTE AVE
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104
Country	:	US
Telephone Number	:	913-302-9317
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2013
Last Update Date	:	09/24/2013

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