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General NPI Number Information
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NPI Number | 1295041630
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Entity Type | Individual
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Provider Name | MR. JASON C SCHICKEDANZ
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Gender | Male
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Dates
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Enumeration Date | 08/24/2010
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Last Update Date | 02/27/2023
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Provider Practice Location Address
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Address Line | 4737 AFTON PL. SANCTUARY NTC STE #A
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City | CHUBUCK
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State | ID
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Zip | 83202
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Country | US
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Telephone | 208-417-0623
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Fax | 208-417-0641
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Provider Business Mailing Address
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Address Line | 4737 AFTON PL. SANCTUARY NTC STE #A
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City | CHUBUCK
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State | ID
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Zip | 83202
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Country | US
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Telephone | 208-417-0623
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Fax | 208-417-0641
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY-203074
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License Number State | ID
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