Healthcare Provider Details

I. General information

NPI: 1982196291
Provider Name (Legal Business Name): JACE PATRICK PUCKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 PERIMETER DR
MOSCOW ID
83844-9803
US

IV. Provider business mailing address

2306 WHITE AVE APT 203
MOSCOW ID
83843-5099
US

V. Phone/Fax

Practice location:
  • Phone: 775-351-8297
  • Fax:
Mailing address:
  • Phone: 775-351-8297
  • 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: