MEDICARE: JARED R KING DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	070019135	IL

General Provider Information

NPI Number	:	1043507494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JARED R KING DPT

Provider Business Mailing Address
First Line	:	3059 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4131
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3059 W 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4131
Country	:	US
Telephone Number	:	773-696-9050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	01/07/2013

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