Provider Demographics
NPI:1164087631
Name:VINSON, JARED LEE (DO)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:LEE
Last Name:VINSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 MDSS/GME
Mailing Address - Street 2:301 FISHER ST, RM 1G123
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534
Mailing Address - Country:US
Mailing Address - Phone:228-376-3728
Mailing Address - Fax:
Practice Address - Street 1:81 MDSS/GME
Practice Address - Street 2:301 FISHER ST, RM1G123
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534
Practice Address - Country:US
Practice Address - Phone:228-376-3728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0068113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program