Healthcare Provider Details

I. General information

NPI: 1730559733
Provider Name (Legal Business Name): JESSICA HERNDON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 S MAIN ST
MOULTRIE GA
31768-6925
US

IV. Provider business mailing address

1 ASHLEY PARK PL APT 406E
THOMASVILLE GA
31792-6391
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-3420
  • Fax:
Mailing address:
  • Phone: 803-261-4537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002504
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: