Provider Demographics
NPI:1942761457
Name:MCCAW, JENNIFER MARAGRET
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:MARAGRET
Last Name:MCCAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 E LEWIS ST STE 10
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6408
Mailing Address - Country:US
Mailing Address - Phone:208-269-2360
Mailing Address - Fax:
Practice Address - Street 1:335 E LEWIS ST STE 10
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6408
Practice Address - Country:US
Practice Address - Phone:208-269-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000038812OtherATHLETIC TRAINING BOARD OF CERTIFICATION