Healthcare Provider Details

I. General information

NPI: 1053840413
Provider Name (Legal Business Name): JACQUELINE ANNE LUPTON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE ANNE LLOYD LAT, ATC

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 08/13/2023
Certification Date: 08/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 STILLWOOD DR
SAVANNAH GA
31419-2643
US

IV. Provider business mailing address

824 STILLWOOD DR
SAVANNAH GA
31419-2643
US

V. Phone/Fax

Practice location:
  • Phone: 912-961-8764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAT004124
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000028113
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: