Healthcare Provider Details

I. General information

NPI: 1225993991
Provider Name (Legal Business Name): JARED PONCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 8TH AVE
FORT WORTH TX
76104-4110
US

IV. Provider business mailing address

2301 W ROSEDALE ST S
FORT WORTH TX
76110-1137
US

V. Phone/Fax

Practice location:
  • Phone: 432-894-9845
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number944353
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: