=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922581362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED KEITH BAKER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2018
-----------------------------------------------------
Last Update Date | 09/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 E BACON ST
-----------------------------------------------------
City | HILLSDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49242-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-224-2062
-----------------------------------------------------
Fax | 517-224-2062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6573 SWEET CLOVER HILLS DR
-----------------------------------------------------
City | JONESVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49250-9123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-877-0436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6301013237
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------