Individual
JACKSON RYAN BRUNNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LAT, ATC
Contact information
Practice address
7160 ATHLETICS KAUFMAN FOOTBALL BUILDING, NORMAL, IL 61790-6953
(309) 438-0607
Mailing address
7160 ATHLETICS KAUFMAN FOOTBALL BUILDING, NORMAL, IL 61790-0001
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
096.004944
IL
Other
Enumeration date
10/10/2018
Last updated
09/28/2021
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