Provider Demographics
NPI:1285137786
Name:BELLON, JAKE (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BELLON
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3109
Practice Address - Country:US
Practice Address - Phone:660-831-4195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160292372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer