Provider Demographics
NPI:1114241122
Name:BRASHEAR, JARRET
Entity Type:Individual
Prefix:
First Name:JARRET
Middle Name:
Last Name:BRASHEAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 TULANE AVE
Mailing Address - Street 2:RM 734
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2865
Mailing Address - Country:US
Mailing Address - Phone:504-568-4760
Mailing Address - Fax:
Practice Address - Street 1:200 W ESPLANADE AVE STE 401
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2475
Practice Address - Country:US
Practice Address - Phone:045-464-8588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA205549208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2106112Medicaid