Provider Demographics
NPI:1407127756
Name:THREAT, JACQUELYNN ANN (ATC)
Entity Type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:ANN
Last Name:THREAT
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 1:2725 W WIGWAM AVE
Mailing Address - Street 2:APT. 1108
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6603
Mailing Address - Country:US
Mailing Address - Phone:415-533-4085
Mailing Address - Fax:
Practice Address - Street 1:2725 W WIGWAM AVE
Practice Address - Street 2:APT. 1108
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-6603
Practice Address - Country:US
Practice Address - Phone:415-533-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05061662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer