Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 078557 | IA |
N | 2251S0007X | Physical Therapist - Sports | 54024 | IA |
NPI | 1154802601 |
---|---|
Provider Name | Jason Engelken |
First Address | Decorah, IA 52101-2325 |
Second Address | Decorah, IA 52101-2325 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2018 |
Last Update Date | 23/08/2018 |