Provider Demographics
NPI:1003203068
Name:DURST, JACQUELINE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DURST
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 FROST AVE
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-1623
Mailing Address - Country:US
Mailing Address - Phone:301-697-2801
Mailing Address - Fax:
Practice Address - Street 1:101 BRADDOCK RD
Practice Address - Street 2:FROSTBURG STATE UNIVERSITY KINESIOLOGY DEPARTMENT
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-2303
Practice Address - Country:US
Practice Address - Phone:301-697-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00192207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine