Healthcare Provider Details

I. General information

NPI: 1992683403
Provider Name (Legal Business Name): JACOB MICHAEL NARDONE LAT, ATC
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 1ST AVE NE
CEDAR RAPIDS IA
52402-5092
US

IV. Provider business mailing address

704 HILLSIDE DR
TIFFIN IA
52340-8404
US

V. Phone/Fax

Practice location:
  • Phone: 319-399-8144
  • Fax:
Mailing address:
  • Phone: 630-450-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number121007
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: