=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720609894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILLIAN BRENNA PERRAULT ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2020
-----------------------------------------------------
Last Update Date | 07/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5823 WIDEWATERS PKWY
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-3084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-483-3782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 ABBEY RD
-----------------------------------------------------
City | ELMIRA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14905-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-483-3782
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------