Healthcare Provider Details

I. General information

NPI: 1851926729
Provider Name (Legal Business Name): JACOB DANIEL PSZANKA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 WELLNESS AND RECREATION CENTER
CEDAR FALLS IA
50614-0001
US

IV. Provider business mailing address

1510 FREDRICK AVE
CLEMONS IA
50051-9637
US

V. Phone/Fax

Practice location:
  • Phone: 319-273-2654
  • Fax:
Mailing address:
  • Phone: 641-485-5654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number092973
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: