Healthcare Provider Details

I. General information

NPI: 1811340128
Provider Name (Legal Business Name): JERICA COLEMAN MED, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 02/07/2025
Certification Date: 02/05/2025
Deactivation Date: 08/15/2021
Reactivation Date: 10/07/2021

III. Provider practice location address

48TH MDG / RAF LAKENHEATH UNIT 5115
APO AE
09461
US

IV. Provider business mailing address

48TH MDG / RAF LAKENHEATH UNIT 5115
APO AE
09461
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-5781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT4795
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: