Healthcare Provider Details

I. General information

NPI: 1417616723
Provider Name (Legal Business Name): JAROD ANTHONY MICEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 CARROLLWOOD PL CIR APT 306
TAMPA FL
33624
US

IV. Provider business mailing address

3902 CARROLLWOOD PL CIR APT 306
TAMPA FL
33624
US

V. Phone/Fax

Practice location:
  • Phone: 402-968-0675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT8817
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: