Healthcare Provider Details

I. General information

NPI: 1285175422
Provider Name (Legal Business Name): JILLIAN MARTENSON A.T., A.T.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILLIAN KAUPPI A.T., A.T.C

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10860 HIGHLAND RD
HARTLAND MI
48353-2629
US

IV. Provider business mailing address

10860 HIGHLAND RD
HARTLAND MI
48353-2629
US

V. Phone/Fax

Practice location:
  • Phone: 810-632-1000
  • Fax:
Mailing address:
  • Phone: 810-632-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601000268
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: