Provider Demographics
NPI:1295041630
Name:SCHICKEDANZ, JASON C
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:C
Last Name:SCHICKEDANZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4737 AFTON PL. SANCTUARY NTC
Mailing Address - Street 2:STE #A
Mailing Address - City:CHUBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202
Mailing Address - Country:US
Mailing Address - Phone:208-417-0623
Mailing Address - Fax:208-417-0641
Practice Address - Street 1:4737 AFTON PL. SANCTUARY NTC
Practice Address - Street 2:STE #A
Practice Address - City:CHUBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:208-417-0623
Practice Address - Fax:208-417-0641
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203074103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist