Healthcare Provider Details

I. General information

NPI: 1104253566
Provider Name (Legal Business Name): JARED DEVIN MINKEL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 W RIVER ST
PROVIDENCE RI
02904-2609
US

IV. Provider business mailing address

117 ELLENFIELD ST 101
PROVIDENCE RI
02905-4513
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-7442
  • Fax: 401-444-7019
Mailing address:
  • Phone: 401-444-4318
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01472
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: