Provider Demographics
NPI:1205351673
Name:LICHMAN, JARED JAMES (DPT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:JAMES
Last Name:LICHMAN
Suffix:
Gender:M
Credentials:DPT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S TAFT AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-7345
Mailing Address - Country:US
Mailing Address - Phone:641-450-0616
Mailing Address - Fax:
Practice Address - Street 1:825 S TAFT AVE STE 4
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-7345
Practice Address - Country:US
Practice Address - Phone:641-450-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IA0928912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer