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General NPI Number Information
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NPI Number | 1629625363
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Entity Type | Individual
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Provider Name | JACOB DANIEL WOODARD ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 08/19/2019
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 1411 W BADDOUR PKWY
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City | LEBANON
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State | TN
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Zip | 37087-2513
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Country | US
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Telephone | 615-444-8262
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Fax |
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Provider Business Mailing Address
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Address Line | 331 PIG BRANCH RD
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City | BRUSH CREEK
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State | TN
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Zip | 38547-5116
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Country | US
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Telephone | 615-489-0621
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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 | AT0000002113
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License Number State | TN
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