Healthcare Provider Details

I. General information

NPI: 1124092390
Provider Name (Legal Business Name): TODD JACOB JAGER I ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAMPUS DR GRAND VALLEY STATE UNIVERSITY, 84 FIELD HOUSE
ALLENDALE MI
49401-9401
US

IV. Provider business mailing address

1 CAMPUS DR GRAND VALLEY STATE UNIVERSITY, 84 FIELD HOUSE
ALLENDALE MI
49401-9401
US

V. Phone/Fax

Practice location:
  • Phone: 616-331-3329
  • Fax: 616-331-3232
Mailing address:
  • Phone: 616-331-3329
  • Fax: 616-331-3232

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: