Provider Demographics
NPI:1194813626
Name:VINC, JARED D (PTA, ATC)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:D
Last Name:VINC
Suffix:
Gender:M
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:PA
Mailing Address - Zip Code:17925-8835
Mailing Address - Country:US
Mailing Address - Phone:570-617-6712
Mailing Address - Fax:
Practice Address - Street 1:329 GREEN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:PA
Practice Address - Zip Code:17925-8835
Practice Address - Country:US
Practice Address - Phone:570-617-6712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
PATE009382225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer