Provider Demographics
NPI:1720162100
Name:BREAKEY, JON MICHAEL (PT DPT)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:MICHAEL
Last Name:BREAKEY
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 HANOVER PIKE
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074
Mailing Address - Country:US
Mailing Address - Phone:410-239-2408
Mailing Address - Fax:410-239-2293
Practice Address - Street 1:1801 HANOVER PIKE
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:MD
Practice Address - Zip Code:21074
Practice Address - Country:US
Practice Address - Phone:410-239-2408
Practice Address - Fax:410-239-2293
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15423225100000X
PAPT015802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD35086101OtherBLUE CROSS BLUE SHIELD
MDR6390001OtherFEDERAL BLUE CROSS
MD321811OtherMAMSI
MD559M866FMedicare ID - Type Unspecified