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General NPI Number Information
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NPI Number | 1306446489
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Entity Type | Individual
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Provider Name | JEPTHE SOULOUQUE MS LAT ATC
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Gender | Male
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Dates
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Enumeration Date | 10/28/2020
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Last Update Date | 10/28/2020
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Provider Practice Location Address
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Address Line | 235 BAKER ST
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City | WEST ROXBURY
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State | MA
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Zip | 02132-4395
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Country | US
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Telephone | 617-469-8055
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Fax |
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Provider Business Mailing Address
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Address Line | 48 CROSS ST
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City | EVERETT
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State | MA
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Zip | 02149-1820
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Country | US
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Telephone | 617-913-6113
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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 | 30544
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License Number State | MA
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