Healthcare Provider Details

I. General information

NPI: 1992019285
Provider Name (Legal Business Name): JARED PLUMMER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 EAGLES NEST LN
OXFORD MS
38655-5990
US

IV. Provider business mailing address

210 EAGLES NEST LN
OXFORD MS
38655-5990
US

V. Phone/Fax

Practice location:
  • Phone: 662-816-6575
  • Fax: 662-915-1833
Mailing address:
  • Phone: 662-816-6575
  • Fax: 662-915-1833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0515
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: