=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508778085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB FLYNN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2026
-----------------------------------------------------
Last Update Date | 09/21/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 20TH ST S
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-361-7146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 20TH ST S
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 17204-24
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------