Healthcare Provider Details

I. General information

NPI: 1255163879
Provider Name (Legal Business Name): JARED ALDEN LOCKE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N ALAFAYA TRL
ORLANDO FL
32826-4726
US

IV. Provider business mailing address

1900 N ALAFAYA TRL
ORLANDO FL
32826-4726
US

V. Phone/Fax

Practice location:
  • Phone: 407-514-3657
  • Fax:
Mailing address:
  • Phone: 407-514-3657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPTA31223
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: