Healthcare Provider Details

I. General information

NPI: 1407133358
Provider Name (Legal Business Name): BRIAN M JAGER AT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LAFAYETTE AVE SE
GRAND RAPIDS MI
49503-4656
US

IV. Provider business mailing address

1148 W ADDISON ST APT 1
CHICAGO IL
60613-3806
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-8515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003085
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001294
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: