Provider Demographics
NPI:1235362443
Name:WILLSON, TERRY LUCAS (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LUCAS
Last Name:WILLSON
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 MONUMENT RD
Mailing Address - Street 2:13-C
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6486
Mailing Address - Country:US
Mailing Address - Phone:801-866-2800
Mailing Address - Fax:
Practice Address - Street 1:1325 SAN MARCO BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8568
Practice Address - Country:US
Practice Address - Phone:904-858-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0045532255A2300X
FLAL 31392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA22OtherATHLETIC TRAINER
FL22OtherATHLETIC TRAINER