MEDICARE: JACOB LYNN CHRISTOFFERSON

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
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1083125421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB LYNN CHRISTOFFERSON

Provider Business Mailing Address
First Line	:	8801 HUNTERS LAKE DR APT 1012
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-2859
Country	:	US
Telephone Number	:	801-633-3409
Fax Number	:

Provider Business Practice Location Address
First Line	:	8801 HUNTERS LAKE DR APT 1012
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-2859
Country	:	US
Telephone Number	:	801-633-3409
Fax Number	:

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

Provider Enumeration Date	:	10/12/2017
Last Update Date	:	10/12/2017

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