Provider Demographics
NPI:1083965461
Name:ALEXANDER, JARED LYNN (IDC)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:LYNN
Last Name:ALEXANDER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 THIBODO RD APT 207
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-7944
Mailing Address - Country:US
Mailing Address - Phone:406-529-1124
Mailing Address - Fax:
Practice Address - Street 1:USS LPD 9 DENVER
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96663-1712
Practice Address - Country:US
Practice Address - Phone:0118195-650-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman