Provider Demographics
NPI:1023671914
Name:COBURN, JERAD (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:JERAD
Middle Name:
Last Name:COBURN
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 1:11811 OWENS CANYON LN
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-2809
Mailing Address - Country:US
Mailing Address - Phone:765-318-9446
Mailing Address - Fax:
Practice Address - Street 1:11811 OWENS CANYON LN
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-2809
Practice Address - Country:US
Practice Address - Phone:765-318-9446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT46742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer