Provider Demographics
NPI:1437779212
Name:BURGOON, JACOB ALLEN
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALLEN
Last Name:BURGOON
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 1:310 LITTLE JOHN DR
Mailing Address - Street 2:
Mailing Address - City:CIRCLE PINES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1721
Mailing Address - Country:US
Mailing Address - Phone:360-223-9941
Mailing Address - Fax:
Practice Address - Street 1:310 LITTLE JOHN DR
Practice Address - Street 2:
Practice Address - City:CIRCLE PINES
Practice Address - State:MN
Practice Address - Zip Code:55014-1721
Practice Address - Country:US
Practice Address - Phone:360-223-9941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer