Healthcare Provider Details

I. General information

NPI: 1295933679
Provider Name (Legal Business Name): MR. JAKE T HOENE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12509 VILLAGE CIRCLE DR
SAINT LOUIS MO
63127-1701
US

IV. Provider business mailing address

1136 OAK BOROUGH DR
BALLWIN MO
63021-8328
US

V. Phone/Fax

Practice location:
  • Phone: 314-270-7790
  • Fax: 314-849-2045
Mailing address:
  • Phone: 636-386-3623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number117618
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: