Healthcare Provider Details

I. General information

NPI: 1306828645
Provider Name (Legal Business Name): JAY PATRICK ANDERSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N STATE ST
ELGIN IL
60123-1404
US

IV. Provider business mailing address

357 CORRINE AVE
CRYSTAL LAKE IL
60014-5161
US

V. Phone/Fax

Practice location:
  • Phone: 847-628-1592
  • Fax: 847-628-1591
Mailing address:
  • Phone: 815-356-0456
  • Fax: 847-628-1591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number96000601
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: