Provider Demographics
NPI:1861121212
Name:BROCKMANN, JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BROCKMANN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 N POMEROY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-2714
Mailing Address - Country:US
Mailing Address - Phone:707-978-9002
Mailing Address - Fax:
Practice Address - Street 1:18700 N 64TH DR STE 205
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7112
Practice Address - Country:US
Practice Address - Phone:602-277-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9130207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine