MEDICARE: MS. JENNIFER JOHNSON FREESE 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

General Provider Information

NPI Number	:	1487643490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER JOHNSON FREESE ATC

Provider Business Mailing Address
First Line	:	111 CLARENDON TER
Second Line	:
City	:	NEWINGTON
State	:	CT
Zip	:	06111-3609
Country	:	US
Telephone Number	:	860-204-3476
Fax Number	:

Provider Business Practice Location Address
First Line	:	166 ALBANY TPKE
Second Line	:
City	:	CANTON
State	:	CT
Zip	:	06019-2546
Country	:	US
Telephone Number	:	860-693-8835
Fax Number	:

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

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	07/08/2007

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