Healthcare Provider Details

I. General information

NPI: 1588637110
Provider Name (Legal Business Name): JASON D ENGLE MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COLLEGIATE SCHOOL 103 NORTH MOORELAND ROAD
RICHMOND VA
23229
US

IV. Provider business mailing address

9021 MERLIN COURT
GLEN ALLEN VA
23060
US

V. Phone/Fax

Practice location:
  • Phone: 804-754-1558
  • Fax:
Mailing address:
  • Phone: 804-314-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126001054
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: