Healthcare Provider Details

I. General information

NPI: 1053718569
Provider Name (Legal Business Name): JASPER OLIVER CHANG AT, ATC, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALDWELL FIELDHOUSE FACULTY ROAD
PRINCETON NJ
08544-0001
US

IV. Provider business mailing address

186 ESTATES BLVD APT. #13
HAMILTON NJ
08610-2109
US

V. Phone/Fax

Practice location:
  • Phone: 609-258-3527
  • Fax: 609-258-7045
Mailing address:
  • Phone: 562-895-4306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001366
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00211600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: