Provider Demographics
NPI:1003905985
Name:BRENING, JACOB MICHAEL (ATC)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:MICHAEL
Last Name:BRENING
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2191 OLD HARRISON PIKE NW
Mailing Address - Street 2:APT 2
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-1098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 NORTH OCOEE
Practice Address - Street 2:LEE UNIVERSITY ATHLETICS
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311
Practice Address - Country:US
Practice Address - Phone:423-614-8527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000009902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer