Basic Information
| Provider Information | |||||||||
| NPI: | 1942722152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CICERO | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 48 TUNNEL RD | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706244777 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 48 TUNNEL RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706244777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2017 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 481 | KY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 481 | 01 | KY | KENTUCKY STATE LICENSE | OTHER |