Provider Demographics
NPI:1346277977
Name:MANSFIELD, JACK WINN SR (ATC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:WINN
Last Name:MANSFIELD
Suffix:SR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 COLWYN AVE
Mailing Address - Street 2:PO BOX 213
Mailing Address - City:CUMBERLAND GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37724
Mailing Address - Country:US
Mailing Address - Phone:423-869-0802
Mailing Address - Fax:
Practice Address - Street 1:6569 CUMBERLAND GAP PKWY
Practice Address - Street 2:
Practice Address - City:HARROGATE
Practice Address - State:TN
Practice Address - Zip Code:37752-8015
Practice Address - Country:US
Practice Address - Phone:423-869-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAT00000010152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer