Provider Demographics
NPI:1861006447
Name:SCHALLER-WARD, JACOB (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:SCHALLER-WARD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:CO
Mailing Address - Zip Code:80816-0361
Mailing Address - Country:US
Mailing Address - Phone:719-477-3698
Mailing Address - Fax:
Practice Address - Street 1:855 CITADEL DR E
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5304
Practice Address - Country:US
Practice Address - Phone:719-465-1502
Practice Address - Fax:719-465-2087
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist