Healthcare Provider Details

I. General information

NPI: 1952722902
Provider Name (Legal Business Name): JACOB ZANGER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 N OUTER 40 RD STE 202
CHESTERFIELD MO
63005-1364
US

IV. Provider business mailing address

3120 CANNONBALL RD
QUINCY IL
62305-7640
US

V. Phone/Fax

Practice location:
  • Phone: 217-430-1530
  • Fax: 636-728-1793
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070020454
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2014011103
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: