Healthcare Provider Details

I. General information

NPI: 1174427710
Provider Name (Legal Business Name): JACOB ANDREW ROLFES MAT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 OLD CAP AU GRIS RD
TROY MO
63379-2300
US

IV. Provider business mailing address

380 BIRKHEAD RD
WINFIELD MO
63389-3247
US

V. Phone/Fax

Practice location:
  • Phone: 636-775-0635
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2026031416
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: