Healthcare Provider Details

I. General information

NPI: 1164039079
Provider Name (Legal Business Name): JALYN RUTLEDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BOHLER ATHLETIC COMPLEX COUGAR WAY - WSU
PULLMAN WA
99164-0001
US

IV. Provider business mailing address

PO BOX 641602P
PULLMAN WA
99164-1602
US

V. Phone/Fax

Practice location:
  • Phone: 800-462-6847
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number61088729
License Number StateWA

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: