Healthcare Provider Details

I. General information

NPI: 1790429603
Provider Name (Legal Business Name): JARED OWEN HICKEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 8TH ST
RUPERT ID
83350-1599
US

IV. Provider business mailing address

1224 8TH ST
RUPERT ID
83350-1599
US

V. Phone/Fax

Practice location:
  • Phone: 208-436-0481
  • Fax: 208-436-6038
Mailing address:
  • Phone: 208-436-0481
  • Fax: 208-436-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number8171597
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: