Provider Demographics
NPI:1275880015
Name:BRUBAKER, JACOB ROBERT LYNN (CPO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT LYNN
Last Name:BRUBAKER
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 LATOUCHE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4208
Mailing Address - Country:US
Mailing Address - Phone:907-561-1777
Mailing Address - Fax:907-561-2157
Practice Address - Street 1:17927 131ST ST E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-7686
Practice Address - Country:US
Practice Address - Phone:206-790-3890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPO0012Medicaid
AKPO0012Medicaid