=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902689466
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADY JANE KICKLIGHTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2023
-----------------------------------------------------
Last Update Date | 09/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 257 S MAIN ST
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30453-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-557-8990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 BIRDFORD LAKE RD
-----------------------------------------------------
City | GLENNVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30427-6042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-318-5361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------