=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942690953
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE L NEWELL JR. ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2015
-----------------------------------------------------
Last Update Date | 01/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12800 N LAKE SHORE DR
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53097-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-243-2641
-----------------------------------------------------
Fax | 262-243-2969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 835 N CASS ST APT 31
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53202-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-239-3147
-----------------------------------------------------
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 | 1506-39
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------