Provider Demographics
NPI:1063202950
Name:STOLTENBURG, JACKSON (DPT)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:STOLTENBURG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 W 54TH ST N APT 4102
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57107-2125
Mailing Address - Country:US
Mailing Address - Phone:605-520-9485
Mailing Address - Fax:
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1007
Practice Address - Country:US
Practice Address - Phone:605-322-5017
Practice Address - Fax:605-322-5040
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist