Healthcare Provider Details

I. General information

NPI: 1962216101
Provider Name (Legal Business Name): JARROD EVANS HICKS COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2025
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 OLD ETNA RD
LEBANON NH
03766-1937
US

IV. Provider business mailing address

655 S WILLOW ST STE 128
MANCHESTER NH
03103-5723
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-2234
  • Fax:
Mailing address:
  • Phone: 603-893-4515
  • Fax: 866-420-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberOTA008403
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number1113
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: