Provider Demographics
NPI:1881252500
Name:BRISKE, JAMIE LEA (DPT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEA
Last Name:BRISKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57950 LEAVENWORTH ST
Mailing Address - Street 2:MCCONNELL AFB
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67221-3506
Mailing Address - Country:US
Mailing Address - Phone:316-743-5021
Mailing Address - Fax:
Practice Address - Street 1:57950 LEAVENWORTH ST
Practice Address - Street 2:MCCONNELL AFB
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-743-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP18729225100000X
TX1315654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP18729OtherTHE BOARD OF PHYSICAL THERAPY EXAMINERS