Healthcare Provider Details

I. General information

NPI: 1487643490
Provider Name (Legal Business Name): JENNIFER JOHNSON FREESE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 ALBANY TPKE
CANTON CT
06019-2546
US

IV. Provider business mailing address

111 CLARENDON TER
NEWINGTON CT
06111-3609
US

V. Phone/Fax

Practice location:
  • Phone: 860-693-8835
  • Fax:
Mailing address:
  • Phone: 860-204-3476
  • 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: