Healthcare Provider Details

I. General information

NPI: 1922438779
Provider Name (Legal Business Name): JERRY WEBBER LAT, ATC, PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 ELIZABETHTOWN RD
HERSHEY PA
17033-9323
US

IV. Provider business mailing address

3003 ELIZABETHTOWN RD
HERSHEY PA
17033-9323
US

V. Phone/Fax

Practice location:
  • Phone: 717-835-0700
  • Fax: 717-835-0702
Mailing address:
  • Phone: 717-835-0700
  • Fax: 717-835-0702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT00167A
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: