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General NPI Number Information
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NPI Number | 1164213369
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Entity Type | Individual
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Provider Name | JACOB JAMES TOLLEFSON
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Gender |
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Dates
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Enumeration Date | 05/15/2025
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Last Update Date | 05/23/2025
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Provider Practice Location Address
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Address Line | 3650 WOODLAND AVE
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City | WEST DES MOINES
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State | IA
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Zip | 50266-1970
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Country | US
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Telephone | 515-663-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 302 5TH AVE SW
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City | STATE CENTER
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State | IA
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Zip | 50247-2016
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Country | US
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Telephone | 641-485-8639
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 132799
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License Number State | IA
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