=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730398835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE DEEKER ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 HANNA RD
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63021-6771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-415-5719
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 SOLLEY DR
-----------------------------------------------------
City | BALLWIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63021-5242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-394-2940
-----------------------------------------------------
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 | 114069
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------