Provider Demographics
NPI:1134135569
Name:WEICHERS, JARED LINCOLN (DPT)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:LINCOLN
Last Name:WEICHERS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-7945
Mailing Address - Country:US
Mailing Address - Phone:541-210-5674
Mailing Address - Fax:541-210-5674
Practice Address - Street 1:1345 CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7945
Practice Address - Country:US
Practice Address - Phone:541-210-5674
Practice Address - Fax:541-210-5674
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1157800225100000X
AZ9154225100000X
IDPT-2251225100000X
OR63181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8079669Medicaid
NV1650048Medicare PIN