Healthcare Provider Details

I. General information

NPI: 1528356367
Provider Name (Legal Business Name): JARED R WHITEHEAD A.P.R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 IMPERIAL BLVD BLDG 2
LAKE CHARLES LA
70605-5362
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-310-3670
  • Fax: 337-421-1443
Mailing address:
  • Phone: 337-312-8258
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP06501
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: