Healthcare Provider Details

I. General information

NPI: 1770285546
Provider Name (Legal Business Name): JAYMIE LIGHTBOURNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 YORK RD
TOWSON MD
21252-0001
US

IV. Provider business mailing address

3108 KING TREE ST
WHEATON MD
20902-2402
US

V. Phone/Fax

Practice location:
  • Phone: 410-704-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberL231379585648
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: