Provider Demographics
NPI:1205216082
Name:BROSCHA, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BROSCHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 E 15TH ST APT 304
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-5010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 VERMILLION ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:SD
Practice Address - Zip Code:57014-2168
Practice Address - Country:US
Practice Address - Phone:605-563-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0430225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant