Provider Demographics
NPI:1700374220
Name:JARRARD, BRADEN PATRICK (LAT, ATC, NREMT)
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:PATRICK
Last Name:JARRARD
Suffix:
Gender:M
Credentials:LAT, ATC, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 BLACKSTOCK RD
Mailing Address - Street 2:
Mailing Address - City:TALMO
Mailing Address - State:GA
Mailing Address - Zip Code:30575-2025
Mailing Address - Country:US
Mailing Address - Phone:770-533-2007
Mailing Address - Fax:
Practice Address - Street 1:906 E 1ST ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-6701
Practice Address - Country:US
Practice Address - Phone:887-642-4655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3066712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2000028562OtherATHLETIC TRAINER