=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134715105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KASSIDY MORGAN JENSEN AT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2020
-----------------------------------------------------
Last Update Date | 12/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 799 N HEWITT RD
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-487-5179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1325 HAROLD ST
-----------------------------------------------------
City | SCOTTVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49454-9285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-794-7942
-----------------------------------------------------
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 | 2601002306
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------