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General NPI Number Information
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NPI Number | 1235362443
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Entity Type | Individual
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Provider Name | TERRY LUCAS WILLSON ATC, CSCS
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Gender | Male
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Dates
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Enumeration Date | 09/03/2009
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Last Update Date | 08/16/2011
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Provider Practice Location Address
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Address Line | 1325 SAN MARCO BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8568
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Country | US
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Telephone | 904-858-7045
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Fax |
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Provider Business Mailing Address
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Address Line | 355 MONUMENT RD 13-C
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City | JACKSONVILLE
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State | FL
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Zip | 32225-6486
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Country | US
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Telephone | 801-866-2800
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | RT004553
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL 3139
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License Number State | FL
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