Healthcare Provider Details

I. General information

NPI: 1780658310
Provider Name (Legal Business Name): JASON WILLIAM GOOD ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E 5TH ST
ANDERSON IN
46012-3462
US

IV. Provider business mailing address

1920 E 5TH ST
ANDERSON IN
46012-3525
US

V. Phone/Fax

Practice location:
  • Phone: 765-641-4006
  • Fax:
Mailing address:
  • Phone: 937-768-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: