Healthcare Provider Details

I. General information

NPI: 1285137786
Provider Name (Legal Business Name): JAKE BELLON MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLLEGE ST
MARSHALL MO
65340-3109
US

IV. Provider business mailing address

500 E COLLEGE ST
MARSHALL MO
65340-3109
US

V. Phone/Fax

Practice location:
  • Phone: 660-831-4195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2016029237
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: