Healthcare Provider Details

I. General information

NPI: 1962335323
Provider Name (Legal Business Name): JACK MICHAEL ECKSTEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 WALLACE RD
AMES IA
50011-0001
US

IV. Provider business mailing address

4611 MORTENSEN RD UNIT 317
AMES IA
50014-6230
US

V. Phone/Fax

Practice location:
  • Phone: 515-294-8718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: