Provider Demographics
NPI:1225620859
Name:JARRETT, KAELYN RAQUEL
Entity Type:Individual
Prefix:
First Name:KAELYN
Middle Name:RAQUEL
Last Name:JARRETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22721 CHEROKEE ROSE PL
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-3102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14497 N DALE MABRY HWY STE 115N
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2023
Practice Address - Country:US
Practice Address - Phone:813-203-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician