Provider Demographics
NPI:1528558871
Name:CARRICO, JEFFREY REED (ATC/LAT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:REED
Last Name:CARRICO
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 GREYSTONE LN APT 19
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8455
Mailing Address - Country:US
Mailing Address - Phone:312-508-0113
Mailing Address - Fax:
Practice Address - Street 1:CENTRAL MICHIGAN UNIVERSITY 145B ROSE CENTER
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:312-508-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010019512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer