MEDICARE: JESSICA LYNN TOWNSEND ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	0368	SD
2	2255A2300X	Athletic Trainer	13375815-4810	UT

General Provider Information

NPI Number	:	1255614848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LYNN TOWNSEND ATC

Provider Business Mailing Address
First Line	:	635 40TH ST APT 303
Second Line	:
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-1880
Country	:	US
Telephone Number	:	248-561-8834
Fax Number	:

Provider Business Practice Location Address
First Line	:	7274 WARDLEIGH RD BAY J
Second Line	:
City	:	HILL AFB
State	:	UT
Zip	:	84056-5137
Country	:	US
Telephone Number	:	248-561-8834
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	08/25/2023

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