Provider Demographics
NPI:1093726713
Name:BRAKE, JENNIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BRAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:111 W JEFFERSON BLVD
Practice Address - Street 2:STE 100
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1994
Practice Address - Country:US
Practice Address - Phone:574-647-1669
Practice Address - Fax:574-239-6461
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058572A207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000914885OtherBCBS BMG E. BLAIR WARNER
IN000000914879OtherBCBS BMG SPORTS MEDICINE
IN200475200Medicaid
IN162520030Medicare PIN
IN000000914885OtherBCBS BMG E. BLAIR WARNER
IN000000914879OtherBCBS BMG SPORTS MEDICINE
IN200475200Medicaid