Provider Demographics
NPI:1851790570
Name:STOUT, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:STOUT
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 1:710 NE HOLLADAY ST # 150
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2168
Mailing Address - Country:US
Mailing Address - Phone:503-949-1727
Mailing Address - Fax:
Practice Address - Street 1:710 NE HOLLADAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2168
Practice Address - Country:US
Practice Address - Phone:503-949-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60726225100000X
2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist