MEDICARE: MS. JENNIFER L LADNER ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT0477	MS

General Provider Information

NPI Number	:	1083052898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER L LADNER ATC

Provider Business Mailing Address
First Line	:	231 LANTANA BLVD
Second Line	:
City	:	LONG BEACH
State	:	MS
Zip	:	39560-5631
Country	:	US
Telephone Number	:	228-669-0792
Fax Number	:

Provider Business Practice Location Address
First Line	:	5132 BEATLINE RD
Second Line	:	SUITE D
City	:	LONG BEACH
State	:	MS
Zip	:	39560-3869
Country	:	US
Telephone Number	:	228-669-0792
Fax Number	:	228-575-8891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2013
Last Update Date	:	06/13/2013

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