Provider Demographics
NPI:1548790348
Name:LUPER-LARK, JENNIFER LYNN (ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:LUPER-LARK
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 1:647 SIMMONS AVE SE
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-2955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1323 BIA ROUTE 4
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339
Practice Address - Country:US
Practice Address - Phone:605-245-1621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD04902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherATHLETIC TRAINING BOARD OF CERTIFICATION