Provider Demographics
NPI:1235766304
Name:DELOACH, JARED J II (NP)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:J
Last Name:DELOACH
Suffix:II
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 BROAD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2419
Mailing Address - Country:US
Mailing Address - Phone:228-863-8868
Mailing Address - Fax:
Practice Address - Street 1:1391 BROAD AVE STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2419
Practice Address - Country:US
Practice Address - Phone:228-863-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903846363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner