=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861029522
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA RENEE WALDREP LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2020
-----------------------------------------------------
Last Update Date | 03/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10064 STATE HIGHWAY SPUR 264
-----------------------------------------------------
City | QUINLAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75474-8743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-356-1680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 SECOND ST
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75758-2235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | AT6339
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------