Provider Demographics
NPI:1265786107
Name:WICKARD, JAYSON D
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:D
Last Name:WICKARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6229
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-0229
Mailing Address - Country:US
Mailing Address - Phone:866-576-4118
Mailing Address - Fax:877-847-7347
Practice Address - Street 1:2215 6TH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-1327
Practice Address - Country:US
Practice Address - Phone:866-576-4118
Practice Address - Fax:877-847-7347
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH144148146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic