Healthcare Provider Details

I. General information

NPI: 1568919892
Provider Name (Legal Business Name): JARED HUTCHINS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 DAUGHERTY AVE
COTTAGE GROVE OR
97424-4835
US

IV. Provider business mailing address

1530 DAUGHERTY AVE
COTTAGE GROVE OR
97424-4835
US

V. Phone/Fax

Practice location:
  • Phone: 541-729-0001
  • Fax: 541-942-7492
Mailing address:
  • Phone: 541-729-0001
  • Fax: 541-942-7492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT986262
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: