MEDICARE: JAMIE LYNN JOLLIFFE 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	AT-503	ID

General Provider Information

NPI Number	:	1740614437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE LYNN JOLLIFFE ATC

Provider Business Mailing Address
First Line	:	2792 S LAKE VISTA LN
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-5421
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2112 CLEVELAND BLVD
Second Line	:	ATHLETICS
City	:	CALDWELL
State	:	ID
Zip	:	83605-4432
Country	:	US
Telephone Number	:	208-459-5052
Fax Number	:

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

Provider Enumeration Date	:	08/29/2013
Last Update Date	:	08/07/2014

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