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General NPI Number Information
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NPI Number | 1366965733
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Entity Type | Individual
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Provider Name | JACOB HARDY LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 07/18/2017
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Last Update Date | 07/18/2017
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Provider Practice Location Address
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Address Line | 200 CAPITOL ST
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City | CLINTON
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State | MS
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Zip | 39056-4026
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Country | US
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Telephone | 769-798-7138
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Fax |
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Provider Business Mailing Address
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Address Line | 203 LAWSON ST
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City | CLINTON
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State | MS
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Zip | 39056-4249
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Country | US
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Telephone | 225-240-9220
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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 | AT0865
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License Number State | MS
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