Provider Demographics
NPI:1508321092
Name:HAWKINS, JACOB (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HAWKINS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S FLORENCE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-2508
Mailing Address - Country:US
Mailing Address - Phone:815-979-4246
Mailing Address - Fax:
Practice Address - Street 1:901 S NATIONAL PROF 160 DEPARTMENT OF SPORTS MEDICINE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0001
Practice Address - Country:US
Practice Address - Phone:417-836-8553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
MO20200261752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program