Healthcare Provider Details

I. General information

NPI: 1982944302
Provider Name (Legal Business Name): JENNIFER BASINI ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LAKE DR
RANDOLPH NJ
07869-4165
US

IV. Provider business mailing address

1 LAKE DR
RANDOLPH NJ
07869-4165
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00051700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: