Healthcare Provider Details

I. General information

NPI: 1124596002
Provider Name (Legal Business Name): JARED VANCE VERRETT RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 COOLIDGE BLVD STE 300
LAFAYETTE LA
70503-2637
US

IV. Provider business mailing address

106 RUE RIDEAU
LAFAYETTE LA
70503-6236
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-0042
  • Fax: 337-289-0043
Mailing address:
  • Phone: 337-303-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN152515
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: