Provider Demographics
NPI:1417716440
Name:BOSAK, JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BOSAK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10114 N BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-3200
Mailing Address - Country:US
Mailing Address - Phone:816-447-1219
Mailing Address - Fax:
Practice Address - Street 1:4029 MILL ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3008
Practice Address - Country:US
Practice Address - Phone:816-285-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-07566208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation