Healthcare Provider Details

I. General information

NPI: 1033741673
Provider Name (Legal Business Name): JENNA THATCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 SOUTH COLLEGE AVENUE
NEWARK DE
19716
US

IV. Provider business mailing address

1109 WOODELA LN
MIDDLETOWN DE
19709-8742
US

V. Phone/Fax

Practice location:
  • Phone: 302-831-6402
  • 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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: