MEDICARE: JARED S. ANDERSON PT, 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	11689PT	AZ

General Provider Information

NPI Number	:	1912375494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JARED S. ANDERSON PT, DPT

Provider Business Mailing Address
First Line	:	1917 N LAKEWOOD DR
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83814-2634
Country	:	US
Telephone Number	:	208-763-0485
Fax Number	:	844-955-2492

Provider Business Practice Location Address
First Line	:	2005 W HAPPY VALLEY RD
Second Line	:	SUITE 170
City	:	PHOENIX
State	:	AZ
Zip	:	85085-2893
Country	:	US
Telephone Number	:	623-322-0654
Fax Number	:	623-322-0664

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

Provider Enumeration Date	:	09/14/2015
Last Update Date	:	01/07/2021

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