MEDICARE: MS. JOLENE ELIZABETH BAKER MA, 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

General Provider Information

NPI Number	:	1760410054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JOLENE ELIZABETH BAKER MA, ATC

Provider Business Mailing Address
First Line	:	6610 N. EMBARCADERO, #5
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219
Country	:	US
Telephone Number	:	209-946-2588
Fax Number	:	209-946-2190

Provider Business Practice Location Address
First Line	:	ATHLETIC DEPARTMENT
Second Line	:	3601 PACIFIC AVE.
City	:	STOCKTON
State	:	CA
Zip	:	95211-0001
Country	:	US
Telephone Number	:	209-946-2588
Fax Number	:

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	07/08/2007

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