MEDICARE: MS. JENNIFER LEE PELTIER 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	1053	SC

General Provider Information

NPI Number	:	1356305494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER LEE PELTIER ATC

Provider Business Mailing Address
First Line	:	PO BOX 751461
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1461
Country	:	US
Telephone Number	:	843-792-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 ASHLEY AVE
Second Line	:	MSC 622
City	:	CHARLESTON
State	:	SC
Zip	:	29425-8900
Country	:	US
Telephone Number	:	843-792-8147
Fax Number	:	843-792-3674

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	04/14/2011

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