Healthcare Provider Details

I. General information

NPI: 1174918924
Provider Name (Legal Business Name): JESSICA DRENTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BEYER HL UNION DRIVE AND RUSSEL ROAD
AMES IA
50011-0001
US

IV. Provider business mailing address

2940 WAGON RD
DECORAH IA
52101-7778
US

V. Phone/Fax

Practice location:
  • Phone: 515-294-5146
  • Fax:
Mailing address:
  • Phone: 563-379-3042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000911
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: