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General NPI Number Information
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NPI Number | 1306828645
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Entity Type | Individual
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Provider Name | JAY PATRICK ANDERSON ATC
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Gender | Male
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Dates
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Enumeration Date | 11/14/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1151 N STATE ST
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City | ELGIN
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State | IL
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Zip | 60123-1404
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Country | US
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Telephone | 847-628-1592
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Fax | 847-628-1591
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Provider Business Mailing Address
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Address Line | 357 CORRINE AVE
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-5161
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Country | US
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Telephone | 815-356-0456
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Fax | 847-628-1591
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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 | 96000601
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License Number State | IL
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