=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184131831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE DAVIDSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2018
-----------------------------------------------------
Last Update Date | 01/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14255 PEYTON DR.
-----------------------------------------------------
City | CHINO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-627-3584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17644 BRIGHTMAN AVE
-----------------------------------------------------
City | LAKE ELSINORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------