Basic Information
| Provider Information | |||||||||
| NPI: | 1205870433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRETT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JEROME | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, ATC, CES | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BARRETT | ||||||||
| OtherFirstName: | JB | ||||||||
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| OtherCredential: | MS, ATC, CES | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5316 ZAMORA DR | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631283520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142009540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 633 EMERSON RD STE 20 | ||||||||
| Address2: | |||||||||
| City: | CREVE COEUR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143253068 | ||||||||
| FaxNumber: | 3143253069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 01/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AL 1824 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 2017031789 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 2017031789 | 01 | MO | STATE OF MISSOURI ATHLETIC TRAINER LICENSE | OTHER | 069702613 | 01 | NATA BOC CERTIFICATION | OTHER |