Provider Demographics
NPI:1417364050
Name:STRUBLE, JILL (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:STRUBLE
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 S JOHN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH JUDSON
Mailing Address - State:IN
Mailing Address - Zip Code:46366-8703
Mailing Address - Country:US
Mailing Address - Phone:937-423-0722
Mailing Address - Fax:
Practice Address - Street 1:600 LEGACY PLZ W
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5268
Practice Address - Country:US
Practice Address - Phone:219-362-8761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002178A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
060802297OtherBOARD OF CERTIFICATION
IN36002178AOtherINDIANA ATHLETIC TRAINERS BOARD