Provider Demographics
NPI:1003421355
Name:BRENNER, JACOB J III (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:BRENNER
Suffix:III
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:WI
Mailing Address - Zip Code:54406-0324
Mailing Address - Country:US
Mailing Address - Phone:715-529-3424
Mailing Address - Fax:715-251-6236
Practice Address - Street 1:167 N MAIN ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:WI
Practice Address - Zip Code:54406-9028
Practice Address - Country:US
Practice Address - Phone:715-529-3424
Practice Address - Fax:715-251-6236
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist