MEDICARE: JESSICA BRAKE DPT

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	225100000X	Physical Therapist	05011892A	IN
2	225100000X	Physical Therapist	PT016004	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558739417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BRAKE DPT

Provider Business Mailing Address
First Line	:	5359 SANCTUARY LN
Second Line	:
City	:	SHEFFIELD VILLAGE
State	:	OH
Zip	:	44054-3103
Country	:	US
Telephone Number	:	419-203-8229
Fax Number	:

Provider Business Practice Location Address
First Line	:	5052 WATERFORD DR UNIT 102
Second Line	:
City	:	SHEFFIELD VILLAGE
State	:	OH
Zip	:	44035-1497
Country	:	US
Telephone Number	:	440-934-9950
Fax Number	:

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

Provider Enumeration Date	:	09/09/2015
Last Update Date	:	08/10/2021

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