Healthcare Provider Details

I. General information

NPI: 1437428778
Provider Name (Legal Business Name): JESSICA LYNN WHALLEY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD
MUNSTER IN
46321-2901
US

IV. Provider business mailing address

901 MACARTHUR BLVD
MUNSTER IN
46321-2901
US

V. Phone/Fax

Practice location:
  • Phone: 614-403-3572
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001650A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: