Provider Demographics
NPI:1245807437
Name:GARDNER, JARRETT
Entity Type:Individual
Prefix:
First Name:JARRETT
Middle Name:
Last Name:GARDNER
Suffix:
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 1:6944 NW DAFFODIL LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15818 SW WARFIELD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANTOWN
Practice Address - State:FL
Practice Address - Zip Code:34956-3513
Practice Address - Country:US
Practice Address - Phone:561-616-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty