Provider Demographics
NPI:1619362852
Name:WILLARD, JARED (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:WILLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-2632
Mailing Address - Fax:
Practice Address - Street 1:3601 THE VANDERBILT CLINIC
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-2640
Practice Address - Country:US
Practice Address - Phone:615-322-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-04
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000058974207R00000X, 207RS0010X, 208000000X, 207R00000X
IL036155928207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine