Provider Demographics
NPI:1316506595
Name:STOCKLAND, JACOB JOSIAH (LAT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOSIAH
Last Name:STOCKLAND
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 SWEETBRIAR DR APT 402
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6728
Mailing Address - Country:US
Mailing Address - Phone:254-251-7959
Mailing Address - Fax:
Practice Address - Street 1:2237 S. JACKSON
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904
Practice Address - Country:US
Practice Address - Phone:325-481-2036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT78922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer