Healthcare Provider Details

I. General information

NPI: 1073608378
Provider Name (Legal Business Name): PICU ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

PO BOX 994032
REDDING CA
96099
US

V. Phone/Fax

Practice location:
  • Phone: 208-429-6693
  • Fax:
Mailing address:
  • Phone: 530-241-0473
  • Fax: 530-241-5377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL W JANSEN
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 208-429-6693