Healthcare Provider Details

I. General information

NPI: 1821563453
Provider Name (Legal Business Name): JACKSON RYAN BRUNNER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7160 ATHLETICS KAUFMAN FOOTBALL BUILDING
NORMAL IL
61790-6953
US

IV. Provider business mailing address

7160 ATHLETICS KAUFMAN FOOTBALL BUILDING
NORMAL IL
61790-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-0607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.004944
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: