Healthcare Provider Details

I. General information

NPI: 1164363479
Provider Name (Legal Business Name): JARED MICHAEL LEATHERMAN R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14014 MARSH PIKE
HAGERSTOWN MD
21742-1638
US

IV. Provider business mailing address

PO BOX 4504
HAGERSTOWN MD
21742-0504
US

V. Phone/Fax

Practice location:
  • Phone: 301-733-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR227428
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: