Provider Demographics
NPI:1164935201
Name:ZACHARY, JARED ALEXANDER I
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:ALEXANDER
Last Name:ZACHARY
Suffix:I
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 1:126 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-3044
Practice Address - Country:US
Practice Address - Phone:760-271-4855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720333537Medicaid