Provider Demographics
NPI:1376748152
Name:ALLSTOT, JAKE RYAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:RYAN
Last Name:ALLSTOT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S LINCOLN ST APT 202S
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2936
Mailing Address - Country:US
Mailing Address - Phone:509-869-8741
Mailing Address - Fax:
Practice Address - Street 1:601 S PARK RD STE 1
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99212-4517
Practice Address - Country:US
Practice Address - Phone:509-921-7818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-2143225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant