Healthcare Provider Details

I. General information

NPI: 1336726835
Provider Name (Legal Business Name): JARED CARLTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NMRTU FALLON 4755 PASTURE RD
FALLON NV
89406
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

V. Phone/Fax

Practice location:
  • Phone: 775-426-3120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101276734
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101276734
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: