Healthcare Provider Details

I. General information

NPI: 1366965733
Provider Name (Legal Business Name): JACOB HARDY LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CAPITOL ST
CLINTON MS
39056-4026
US

IV. Provider business mailing address

203 LAWSON ST
CLINTON MS
39056-4249
US

V. Phone/Fax

Practice location:
  • Phone: 769-798-7138
  • Fax:
Mailing address:
  • Phone: 225-240-9220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0865
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: