Provider Demographics
NPI:1851799548
Name:HALL, JACQUELYN (ATC)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2477
Mailing Address - Country:US
Mailing Address - Phone:231-876-5000
Mailing Address - Fax:
Practice Address - Street 1:400 LINDEN ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-1704
Practice Address - Country:US
Practice Address - Phone:231-876-5876
Practice Address - Fax:231-876-5886
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010009062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer