Provider Demographics
NPI:1518515626
Name:VINCENT, JARED BLAKE
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:BLAKE
Last Name:VINCENT
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:PO BOX 2731
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78691-2731
Mailing Address - Country:US
Mailing Address - Phone:512-598-1411
Mailing Address - Fax:
Practice Address - Street 1:16845 TORTOISE ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-8604
Practice Address - Country:US
Practice Address - Phone:512-598-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-01
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No347C00000XTransportation ServicesPrivate Vehicle