Healthcare Provider Details

I. General information

NPI: 1396719217
Provider Name (Legal Business Name): KELLY M JAEGER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SAN PABLO ST SPORTS MEDICINE DEPARTMENT
LOS ANGELES CA
90033-5313
US

IV. Provider business mailing address

5141 CARTWRIGHT AVE
NORTH HOLLYWOOD CA
91601-4023
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-5338
  • Fax:
Mailing address:
  • Phone: 818-755-0084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: