Healthcare Provider Details

I. General information

NPI: 1134578347
Provider Name (Legal Business Name): ANDREW JEDLICKA MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 27TH ST
DES MOINES IA
50311-3020
US

IV. Provider business mailing address

1421 27TH ST
DES MOINES IA
50311-3020
US

V. Phone/Fax

Practice location:
  • Phone: 563-219-2200
  • Fax:
Mailing address:
  • Phone: 563-219-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number000918
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number1926-39
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: