Healthcare Provider Details

I. General information

NPI: 1588639355
Provider Name (Legal Business Name): JESSICA SUE DETTORE ATC, MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S WATER ST
PITTSBURGH PA
15203-2307
US

IV. Provider business mailing address

119 BAYWOOD AVE APT. 7B
PITTSBURGH PA
15228-1349
US

V. Phone/Fax

Practice location:
  • Phone: 412-432-3770
  • Fax:
Mailing address:
  • Phone: 724-494-3234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT003697
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: