MEDICARE: JARED NEAL AT

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1790304889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JARED NEAL AT

Provider Business Mailing Address
First Line	:	12118 W HINSDALE CT
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-4771
Country	:	US
Telephone Number	:	208-860-5356
Fax Number	:

Provider Business Practice Location Address
First Line	:	12118 W HINSDALE CT
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-4771
Country	:	US
Telephone Number	:	208-860-5356
Fax Number	:

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

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	04/09/2020

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Directions to “ JARED NEAL AT” Practice Location

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