Provider Demographics
NPI:1538351366
Name:PROBST, JEFFREY A (ATC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:PROBST
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:TEUTOPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62467-1228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 EAST EMERSON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-2900
Practice Address - Country:US
Practice Address - Phone:309-556-3601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer