Provider Demographics
NPI:1851907422
Name:JUSTICE, JARED MICHAEL
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:MICHAEL
Last Name:JUSTICE
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 1:3520 W SIEBENTHALER AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1534
Mailing Address - Country:US
Mailing Address - Phone:937-567-9578
Mailing Address - Fax:
Practice Address - Street 1:3520 W SIEBENTHALER AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1534
Practice Address - Country:US
Practice Address - Phone:937-567-9578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-19
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0215321835P0018X
OH034396161835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist