Healthcare Provider Details

I. General information

NPI: 1235945205
Provider Name (Legal Business Name): JACOB HUTCHERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 WESTWOOD RD
WINONA LAKE IN
46590-1745
US

IV. Provider business mailing address

2301 WESTWOOD RD
WINONA LAKE IN
46590-1745
US

V. Phone/Fax

Practice location:
  • Phone: 574-376-9126
  • Fax:
Mailing address:
  • Phone: 574-376-9126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: