Provider Demographics
NPI:1386039816
Name:PICKARD, JERRY VANCE (EDD, ATC, LAT)
Entity Type:Individual
Prefix:PROF
First Name:JERRY
Middle Name:VANCE
Last Name:PICKARD
Suffix:
Gender:M
Credentials:EDD, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4925 BOONSBORO RD # 190
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2240
Mailing Address - Country:US
Mailing Address - Phone:434-592-3762
Mailing Address - Fax:
Practice Address - Street 1:4925 BOONSBORO RD # 190
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24503-2240
Practice Address - Country:US
Practice Address - Phone:434-592-3762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260007262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer