Provider Demographics
NPI:1346762341
Name:BREKKEN, JACOB (PA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BREKKEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S ILLINOIS AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 4TH ST SW STE 105
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2856
Practice Address - Country:US
Practice Address - Phone:641-428-7847
Practice Address - Fax:641-428-7999
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA88259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant