MEDICARE: MRS. JENNA LYNN DECRAENE A.T.C., 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	36001248A	IN

General Provider Information

NPI Number	:	1902860141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNA LYNN DECRAENE A.T.C., LAT

Provider Business Mailing Address
First Line	:	952 SKILLET AVE
Second Line	:
City	:	HUNTERTOWN
State	:	IN
Zip	:	46748-0109
Country	:	US
Telephone Number	:	260-515-0065
Fax Number	:

Provider Business Practice Location Address
First Line	:	7920 W JEFFERSON BLVD
Second Line	:	SUITE 100
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4168
Country	:	US
Telephone Number	:	260-459-0917
Fax Number	:

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	08/27/2022

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