Healthcare Provider Details

I. General information

NPI: 1609262872
Provider Name (Legal Business Name): JAMIE SUPERAK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9341 FRAMINGTON WAY
ELK GROVE CA
95758-4014
US

IV. Provider business mailing address

9341 FRAMINGTON WAY
ELK GROVE CA
95758-4014
US

V. Phone/Fax

Practice location:
  • Phone: 916-599-2317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: