Provider Demographics
NPI:1558916718
Name:PURCELL, JESSE MILLER (ATC)
Entity Type:Individual
Prefix:MS
First Name:JESSE
Middle Name:MILLER
Last Name:PURCELL
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 1:500 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-6400
Mailing Address - Country:US
Mailing Address - Phone:909-607-9958
Mailing Address - Fax:
Practice Address - Street 1:500 E 9TH ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-6400
Practice Address - Country:US
Practice Address - Phone:909-607-9958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000014477OtherBOC CERTIFIED ATHLETIC TRAINER