Provider Demographics
NPI:1497125090
Name:SCHULTZ, JACOB (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-4932
Mailing Address - Country:US
Mailing Address - Phone:920-451-5559
Mailing Address - Fax:
Practice Address - Street 1:2629 N 7TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-4932
Practice Address - Country:US
Practice Address - Phone:920-451-5559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2018-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer