Provider Demographics
NPI:1598459810
Name:KLOTH, JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KLOTH
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 1:200 W DOUGLAS AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3002
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:
Practice Address - Street 1:712 1ST TER STE 103
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:KS
Practice Address - Zip Code:66043-1715
Practice Address - Country:US
Practice Address - Phone:913-727-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-07490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist