Provider Demographics
NPI:1487031837
Name:BRUNELLO, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BRUNELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:BRUNELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:101 CIRBY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-4360
Mailing Address - Country:US
Mailing Address - Phone:916-787-8836
Mailing Address - Fax:
Practice Address - Street 1:101 CIRBY HILLS DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-4360
Practice Address - Country:US
Practice Address - Phone:916-787-8836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program