Healthcare Provider Details

I. General information

NPI: 1467706994
Provider Name (Legal Business Name): JENA LYNNE ETNOYER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 ROCKVILLE PIKE STE E
ROCKVILLE MD
20852-1267
US

IV. Provider business mailing address

9300 LIVINGSTON RD SUITE 100
FORT WASHINGTON MD
20744-4914
US

V. Phone/Fax

Practice location:
  • Phone: 301-251-2777
  • Fax:
Mailing address:
  • Phone: 301-251-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: