Provider Demographics
NPI:1316513526
Name:BLANK, JARED ALLEN (DPT)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:ALLEN
Last Name:BLANK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-817-4277
Mailing Address - Fax:
Practice Address - Street 1:8726 US 42
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-817-7848
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT0192302251X0800X
KY0082552251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic