=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083129241
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA ELIZABETH JENKS ATC, CSCS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2017
-----------------------------------------------------
Last Update Date | 12/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 395 DANBURY RD
-----------------------------------------------------
City | WILTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06897-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-762-0381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 LYNLEE LN
-----------------------------------------------------
City | WILTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06897-1103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-644-2429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 000911
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------