=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588220107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN M COHEN ED. D, ATC, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2019
-----------------------------------------------------
Last Update Date | 05/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1760 DOWN RIVER DR
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98674-9699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-624-8057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1052 SONOMA AVE
-----------------------------------------------------
City | MENLO PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94025-1740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-714-9761
-----------------------------------------------------
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 | 942248
-----------------------------------------------------
License Number State |
-----------------------------------------------------