Provider Demographics
NPI:1528356367
Name:WHITEHEAD, JARED R (APRN)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:R
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
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Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8258
Mailing Address - Fax:337-312-6708
Practice Address - Street 1:1727 IMPERIAL BLVD
Practice Address - Street 2:BLDG 2
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5362
Practice Address - Country:US
Practice Address - Phone:337-310-3670
Practice Address - Fax:337-421-1443
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2017-04-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAAP06501363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00981884Medicare PIN
LA3C5637460Medicare PIN