Provider Demographics
NPI:1134578347
Name:JEDLICKA, ANDREW (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:JEDLICKA
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 27TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-3020
Mailing Address - Country:US
Mailing Address - Phone:563-219-2200
Mailing Address - Fax:
Practice Address - Street 1:1421 27TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-3020
Practice Address - Country:US
Practice Address - Phone:563-219-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000918207PS0010X
WI1926-39207PS0010X
IA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine