Individual
JACE PATRICK PUCKETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
875 PERIMETER DR, MOSCOW, ID 83844-9803
(775) 351-8297
Mailing address
2306 WHITE AVE APT 203, MOSCOW, ID 83843-5099
(775) 351-8297
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
—
Other
Enumeration date
06/01/2018
Last updated
06/01/2018
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