Provider Demographics
NPI:1083675763
Name:BRABANDT, JEREMY (PT)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:BRABANDT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-4907
Mailing Address - Country:US
Mailing Address - Phone:904-661-2790
Mailing Address - Fax:904-661-2793
Practice Address - Street 1:221 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-4907
Practice Address - Country:US
Practice Address - Phone:904-661-2790
Practice Address - Fax:904-661-2793
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002576225100000X
KY004749225100000X
OH011539225100000X
FL31733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4188603Medicare PIN
OH4188602Medicare PIN
OH4188601Medicare PIN
WV4188605Medicare PIN
WV4188604Medicare PIN
KY0905805Medicare ID - Type Unspecified