1295327385 NPI number — JACLEEN A LAMPERT ATC

Table of content: JACLEEN A LAMPERT ATC (NPI 1295327385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295327385 NPI number — JACLEEN A LAMPERT ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAMPERT
Provider First Name:
JACLEEN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295327385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12860 E 2500 NORTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61748-7607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-261-4254
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 E RAAB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61761-9487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-261-4254
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 096.001206 . This is a "CERTIFIED ATHLETIC TRAINER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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