Provider Demographics
NPI:1821520313
Name:JAQUA, BREANNE M (DO)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:M
Last Name:JAQUA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:M
Other - Last Name:HIRSHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1501 N GILBERT RD FL 1
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2390
Mailing Address - Country:US
Mailing Address - Phone:480-728-4100
Mailing Address - Fax:
Practice Address - Street 1:1501 N GILBERT RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2390
Practice Address - Country:US
Practice Address - Phone:480-728-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013802207P00000X
390200000X
AZ008620207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program