Provider Demographics
NPI:1164213369
Name:TOLLEFSON, JACOB JAMES
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JAMES
Last Name:TOLLEFSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 5TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:STATE CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:50247-2016
Mailing Address - Country:US
Mailing Address - Phone:641-485-8639
Mailing Address - Fax:
Practice Address - Street 1:3650 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1970
Practice Address - Country:US
Practice Address - Phone:515-663-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-15
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1327992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer