Basic Information
| Provider Information | |||||||||
| NPI: | 1942760384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STERNHAGEN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | CASEY | ||||||||
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| Credential: | MSOTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1637 S BLACK AVE | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597155701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1130 17TH AVE S | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594054523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067714500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OTP-OT-LIC-4675 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.