Provider Demographics
NPI:1821258302
Name:WAKEMAN, JARED (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:WAKEMAN
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 1:2601 TULANE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-7462
Mailing Address - Country:US
Mailing Address - Phone:504-821-2601
Mailing Address - Fax:504-267-3014
Practice Address - Street 1:2601 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7462
Practice Address - Country:US
Practice Address - Phone:504-821-2601
Practice Address - Fax:504-267-3014
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2047022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2396030Medicaid