Provider Demographics
NPI:1508257650
Name:BAKER, JEFFERY ROBERT (MA, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ROBERT
Last Name:BAKER
Suffix:
Gender:M
Credentials:MA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHAMPIONS DR SUITE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65211-0001
Mailing Address - Country:US
Mailing Address - Phone:573-239-8756
Mailing Address - Fax:
Practice Address - Street 1:1 CHAMPIONS DR SUITE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65211-6505
Practice Address - Country:US
Practice Address - Phone:573-239-8756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200352762255A2300X
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer