=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225303456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB SCOTT FREEDLE CMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2012
-----------------------------------------------------
Last Update Date | 03/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10841 S CROSSROADS DR STE 9
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80134-9090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-934-6583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10841 S CROSSROADS DR STE 9
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80134-9090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-934-6583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 13221
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------