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General NPI Number Information
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NPI Number | 1558403402
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Entity Type | Individual
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Provider Name | JASON BRADLEY KITCHENS ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 02/13/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1615 STANLEY ST DEPARTMENT OF PHYSICAL EDUCATION & HUMAN PERFORMANCE
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City | NEW BRITAIN
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State | CT
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Zip | 06050-2439
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Country | US
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Telephone | 203-417-7455
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Fax |
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Provider Business Mailing Address
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Address Line | 1670 FARMINGTON AVE UNIT 6
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City | UNIONVILLE
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State | CT
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Zip | 06085-1229
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Country | US
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Telephone | 203-417-7455
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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 | 000267
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License Number State | CT
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