Provider Demographics
NPI:1285252791
Name:STOTLER, JACOB R
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:STOTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-5302
Mailing Address - Country:US
Mailing Address - Phone:308-627-6119
Mailing Address - Fax:
Practice Address - Street 1:2002 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5302
Practice Address - Country:US
Practice Address - Phone:307-677-1618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY193200000X101YM0800X
WY101YM0800X, 171M00000X
NE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator