Provider Demographics
NPI:1235793043
Name:BRENNAN, JACOB LEWIS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LEWIS
Last Name:BRENNAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25723 OLD FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78015-6605
Mailing Address - Country:US
Mailing Address - Phone:210-450-6810
Mailing Address - Fax:210-450-6023
Practice Address - Street 1:25723 OLD FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78015-6605
Practice Address - Country:US
Practice Address - Phone:210-450-6810
Practice Address - Fax:210-450-6023
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV7191207X00000X
VA0116038844390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery