Healthcare Provider Details

I. General information

NPI: 1295327385
Provider Name (Legal Business Name): JACLEEN A LAMPERT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 E RAAB RD
NORMAL IL
61761-9487
US

IV. Provider business mailing address

12860 E 2500 NORTH RD
HUDSON IL
61748-7607
US

V. Phone/Fax

Practice location:
  • Phone: 309-261-4254
  • Fax:
Mailing address:
  • Phone: 309-261-4254
  • 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: