Basic Information
| Provider Information | |||||||||
| NPI: | 1699381244 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENTON | ||||||||
| FirstName: | JACKY | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8066 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192895809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3676 PARKER BLVD STE 310 | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195957780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2020 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT.0001926 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.