Individual
JENNIFER A BRAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
111 W JEFFERSON BLVD, STE 100, SOUTH BEND, IN 46601-1994
(574) 647-1669
(574) 239-6461
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
01058572A
IN
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
01058572A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000914879
BCBS BMG SPORTS MEDICINE
IN
01
—
000000914885
BCBS BMG E. BLAIR WARNER
IN
05
—
200475200
—
IN
Enumeration date
08/10/2006
Last updated
03/04/2016
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