Healthcare Provider Details

I. General information

NPI: 1609121466
Provider Name (Legal Business Name): JENNIFER LEE SHURTZ MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER LEE WEIDMAN MS, ATC

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3631 S 6TH ST
SPRINGFIELD IL
62703-4777
US

IV. Provider business mailing address

805 RUTH AVE
SPRINGFIELD IL
62702-4841
US

V. Phone/Fax

Practice location:
  • Phone: 217-535-3685
  • Fax:
Mailing address:
  • Phone: 217-619-1905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.002603
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: