=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396296109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE TITTLE ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2016
-----------------------------------------------------
Last Update Date | 10/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 REID PKWY
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47374-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-983-3092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 N 5TH ST
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47374-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-357-1489
-----------------------------------------------------
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 | 261106063
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT003116
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------