Provider Demographics
NPI:1275034225
Name:WENN, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:WENN
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 1:3040 CENTRAL AVE APT I104
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-8618
Mailing Address - Country:US
Mailing Address - Phone:801-368-8821
Mailing Address - Fax:
Practice Address - Street 1:50 OLD VILLAGE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1583
Practice Address - Country:US
Practice Address - Phone:614-544-1976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
STUDENT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program