Healthcare Provider Details

I. General information

NPI: 1629902820
Provider Name (Legal Business Name): JACK ANTONSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7303 S CLIFF AVE
SIOUX FALLS SD
57108-8752
US

IV. Provider business mailing address

47111 298TH ST
BERESFORD SD
57004-6731
US

V. Phone/Fax

Practice location:
  • Phone: 605-961-7250
  • Fax:
Mailing address:
  • Phone: 605-951-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6282
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: