Provider Demographics
NPI:1760620371
Name:BENNETT, JARED JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:JOHN
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 NW 64TH ST STE 160
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1657
Mailing Address - Country:US
Mailing Address - Phone:405-659-5418
Mailing Address - Fax:
Practice Address - Street 1:4045 NW 64TH ST STE 160
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1657
Practice Address - Country:US
Practice Address - Phone:405-659-5418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3918111N00000X
UT8185842-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor