Healthcare Provider Details

I. General information

NPI: 1003203068
Provider Name (Legal Business Name): JACQUELINE DURST ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BRADDOCK RD FROSTBURG STATE UNIVERSITY KINESIOLOGY DEPARTMENT
FROSTBURG MD
21532-2303
US

IV. Provider business mailing address

27 FROST AVE
FROSTBURG MD
21532-1623
US

V. Phone/Fax

Practice location:
  • Phone: 301-697-2801
  • Fax:
Mailing address:
  • Phone: 301-697-2801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberA00192
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: