Healthcare Provider Details

I. General information

NPI: 1154802601
Provider Name (Legal Business Name): JASON ENGELKEN PT, DPT, SCS, ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MONTGOMERY ST
DECORAH IA
52101-2325
US

IV. Provider business mailing address

901 MONTGOMERY ST
DECORAH IA
52101-2325
US

V. Phone/Fax

Practice location:
  • Phone: 563-387-3031
  • Fax: 563-382-1582
Mailing address:
  • Phone: 563-387-3031
  • Fax: 563-382-1582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number078557
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number54024
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: