Provider Demographics
NPI:1790304889
Name:NEAL, JARED (AT)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:NEAL
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12118 W HINSDALE CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-4771
Mailing Address - Country:US
Mailing Address - Phone:208-860-5356
Mailing Address - Fax:
Practice Address - Street 1:12118 W HINSDALE CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-4771
Practice Address - Country:US
Practice Address - Phone:208-860-5356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty