Healthcare Provider Details

I. General information

NPI: 1801812235
Provider Name (Legal Business Name): JILL ELIZABETH STOBBER LAT, A.T.,C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FIELD DR
WATERFORD WI
53185-4116
US

IV. Provider business mailing address

981 CEDAR DR
BURLINGTON WI
53105-1368
US

V. Phone/Fax

Practice location:
  • Phone: 262-534-3189
  • Fax: 262-534-4971
Mailing address:
  • Phone: 262-763-6816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number320-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: