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General NPI Number Information
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NPI Number | 1952708232
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Entity Type | Individual
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Provider Name | JACOB CROW ATC
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Gender | Male
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Dates
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Enumeration Date | 12/02/2014
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Last Update Date | 12/02/2014
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Provider Practice Location Address
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Address Line | 1001 E 17TH ST
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City | BLOOMINGTON
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State | IN
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Zip | 47408-1590
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Country | US
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Telephone | 812-855-3618
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Fax |
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Provider Business Mailing Address
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Address Line | 205 E 6TH ST
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City | BLOOMINGTON
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State | IN
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Zip | 47408-3517
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Country | US
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Telephone | 812-855-3618
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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 | 36002259A
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License Number State | IN
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