MEDICARE: JONATHAN DAVID SEMILLO ATC, LAT

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-10256506	OR

General Provider Information

NPI Number	:	1891592473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN DAVID SEMILLO ATC, LAT

Provider Business Mailing Address
First Line	:	10424 GRASS VALLEY CT
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95209-4549
Country	:	US
Telephone Number	:	209-938-7131
Fax Number	:

Provider Business Practice Location Address
First Line	:	6000 J ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95819-2605
Country	:	US
Telephone Number	:	916-278-9355
Fax Number	:

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

Provider Enumeration Date	:	02/28/2025
Last Update Date	:	01/09/2026

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