Provider Demographics
NPI:1912375494
Name:ANDERSON, JARED S (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 N LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2634
Mailing Address - Country:US
Mailing Address - Phone:208-763-0485
Mailing Address - Fax:844-955-2492
Practice Address - Street 1:2005 W HAPPY VALLEY RD
Practice Address - Street 2:SUITE 170
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-2893
Practice Address - Country:US
Practice Address - Phone:623-322-0654
Practice Address - Fax:623-322-0664
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11689PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist