Provider Demographics
NPI:1154028348
Name:BREWER, JAKE PAUL LELAND (PT, DPT)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:PAUL LELAND
Last Name:BREWER
Suffix:
Gender:
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 1:5310 KIETZKE LN STE 104
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2043
Mailing Address - Country:US
Mailing Address - Phone:775-348-8800
Mailing Address - Fax:
Practice Address - Street 1:9480 DOUBLE DIAMOND PKWY STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-5842
Practice Address - Country:US
Practice Address - Phone:775-348-8800
Practice Address - Fax:833-687-1419
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVJBREWER1995Medicaid