Basic Information
| Provider Information | |||||||||
| NPI: | 1093726713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAKE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 W JEFFERSON BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471669 | ||||||||
| FaxNumber: | 5742396461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 01058572A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 01058572A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000914885 | 01 | IN | BCBS BMG E. BLAIR WARNER | OTHER | 000000914879 | 01 | IN | BCBS BMG SPORTS MEDICINE | OTHER | 200475200 | 05 | IN | MEDICAID |