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General NPI Number Information
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NPI Number | 1316506595
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Entity Type | Individual
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Provider Name | JACOB JOSIAH STOCKLAND LAT
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Gender | Male
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Dates
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Enumeration Date | 06/11/2019
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 2237 S. JACKSON
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City | SAN ANGELO
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State | TX
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Zip | 76904
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Country | US
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Telephone | 325-481-2036
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Fax |
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Provider Business Mailing Address
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Address Line | 2504 SWEETBRIAR DR APT 402
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City | SAN ANGELO
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State | TX
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Zip | 76904-6728
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Country | US
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Telephone | 254-251-7959
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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 | AT7892
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License Number State | TX
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