Provider Demographics
NPI:1275286056
Name:WETSEL, JARED MICHAEL
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:MICHAEL
Last Name:WETSEL
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 1:3511 N NESBITT AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-3381
Mailing Address - Country:US
Mailing Address - Phone:405-205-7343
Mailing Address - Fax:
Practice Address - Street 1:2617 GENERAL PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6437
Practice Address - Country:US
Practice Address - Phone:405-205-7343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist