Healthcare Provider Details

I. General information

NPI: 1457346561
Provider Name (Legal Business Name): TOM MCMAHON JENNINGS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 W 122ND ST
CARMEL IN
46032-3828
US

IV. Provider business mailing address

6959 WASHINGTON BLVD
INDIANAPOLIS IN
46220-1052
US

V. Phone/Fax

Practice location:
  • Phone: 317-691-0102
  • Fax:
Mailing address:
  • Phone: 317-691-0102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000179A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: