Healthcare Provider Details

I. General information

NPI: 1548869571
Provider Name (Legal Business Name): JOSHUA WATERSJACKSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430406 LAS PULGAS
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

PO BOX 2865
OCEANSIDE CA
92051-2865
US

V. Phone/Fax

Practice location:
  • Phone: 760-917-5920
  • Fax:
Mailing address:
  • Phone: 760-917-5920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: