Healthcare Provider Details

I. General information

NPI: 1639627672
Provider Name (Legal Business Name): MRS. JODI SCHLICHTING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SIOUX VALLEY DR
CHEROKEE IA
51012-1205
US

IV. Provider business mailing address

300 SIOUX VALLEY DR
CHEROKEE IA
51012-1205
US

V. Phone/Fax

Practice location:
  • Phone: 712-225-6858
  • Fax:
Mailing address:
  • Phone: 712-225-6858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00222
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: