=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295933679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JAKE T HOENE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12509 VILLAGE CIRCLE DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63127-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-270-7790
-----------------------------------------------------
Fax | 314-849-2045
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1136 OAK BOROUGH DR
-----------------------------------------------------
City | BALLWIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63021-8328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-386-3623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 117618
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------