Healthcare Provider Details

I. General information

NPI: 1134165616
Provider Name (Legal Business Name): DESIREE JEANNE JUBINVILLE A.T.C., NHLAT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MAST RD
GOFFSTOWN NH
03045-2350
US

IV. Provider business mailing address

46 MAST RD
GOFFSTOWN NH
03045-2350
US

V. Phone/Fax

Practice location:
  • Phone: 603-497-8717
  • Fax: 603-497-8711
Mailing address:
  • Phone: 603-361-2072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number295
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: