MEDICARE: JAQUELINE JOAN GRANT LAT, 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		CO

General Provider Information

NPI Number	:	1841801958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAQUELINE JOAN GRANT LAT, ATC

Provider Business Mailing Address
First Line	:	8147 PEARL ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80229-5843
Country	:	US
Telephone Number	:	303-875-0780
Fax Number	:

Provider Business Practice Location Address
First Line	:	2305 PIERCE ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80214-1031
Country	:	US
Telephone Number	:	303-875-0780
Fax Number	:

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

Provider Enumeration Date	:	08/12/2020
Last Update Date	:	10/25/2023

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