Provider Demographics
NPI:1366059289
Name:STONER, JACOB (MBA, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:STONER
Suffix:
Gender:M
Credentials:MBA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 N WILMOT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4427
Mailing Address - Country:US
Mailing Address - Phone:302-242-3106
Mailing Address - Fax:
Practice Address - Street 1:3225 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-4823
Practice Address - Country:US
Practice Address - Phone:302-242-3106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist