Healthcare Provider Details

I. General information

NPI: 1205438652
Provider Name (Legal Business Name): JACOB OUELLETTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 S COLLEGE AVE
NEWARK DE
19716-2010
US

IV. Provider business mailing address

39 ALICE LN
AMSTON CT
06231-1601
US

V. Phone/Fax

Practice location:
  • Phone: 302-831-4016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
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: