=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174427710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB ANDREW ROLFES MAT, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2026
-----------------------------------------------------
Last Update Date | 10/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1190 OLD CAP AU GRIS RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63379-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-775-0635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 380 BIRKHEAD RD
-----------------------------------------------------
City | WINFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63389-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2026031416
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------