Provider Demographics
NPI:1073329504
Name:BRANNON, JACOB THOMAS ADAM (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS ADAM
Last Name:BRANNON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6070 AVENIDA ENCINAS # 100
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6070 AVENIDA ENCINAS # 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1001
Practice Address - Country:US
Practice Address - Phone:760-388-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA307089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist