Provider Demographics
NPI:1114405024
Name:CARTER, JERED JAMES (SUD)
Entity Type:Individual
Prefix:
First Name:JERED
Middle Name:JAMES
Last Name:CARTER
Suffix:
Gender:M
Credentials:SUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-0217
Mailing Address - Country:US
Mailing Address - Phone:509-457-0990
Mailing Address - Fax:
Practice Address - Street 1:2280 SR 821
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901
Practice Address - Country:US
Practice Address - Phone:509-457-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60983949101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)