Provider Demographics
NPI:1033513692
Name:SAILOR, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SAILOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 LUCAS AVE UNIT 508
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1555
Mailing Address - Country:US
Mailing Address - Phone:314-307-4197
Mailing Address - Fax:
Practice Address - Street 1:2206 LUCAS AVE UNIT 508
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1555
Practice Address - Country:US
Practice Address - Phone:314-307-4197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOP059173009171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP059173009OtherCERTIFIED ATHLETIC TRAINER