Provider Demographics
NPI:1437651999
Name:RASMUSSEN, JARED L
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:L
Last Name:RASMUSSEN
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 1:3513 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-5644
Mailing Address - Country:US
Mailing Address - Phone:928-965-2772
Mailing Address - Fax:
Practice Address - Street 1:103 E MEDICINE WAY
Practice Address - Street 2:
Practice Address - City:PERIDOT
Practice Address - State:AZ
Practice Address - Zip Code:85542-8554
Practice Address - Country:US
Practice Address - Phone:928-475-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily