Provider Demographics
NPI:1659259638
Name:HOSTETLER, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:HOSTETLER
Suffix:
Gender:M
Credentials:
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 172
Mailing Address - Street 2:
Mailing Address - City:OAKESDALE
Mailing Address - State:WA
Mailing Address - Zip Code:99158-0172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 W FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WA
Practice Address - Zip Code:99111-9552
Practice Address - Country:US
Practice Address - Phone:509-397-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant