Healthcare Provider Details

I. General information

NPI: 1184390643
Provider Name (Legal Business Name): JENNIFER STANSHAW-BASA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER STANSHAW ATC

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5199 IVY ST
COMMERCE CITY CO
80022-4404
US

IV. Provider business mailing address

5080 SPECTRUM DR STE 1200W
ADDISON TX
75001-4624
US

V. Phone/Fax

Practice location:
  • Phone: 800-289-3595
  • Fax:
Mailing address:
  • Phone: 469-261-4337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000000185
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: