Provider Demographics
NPI:1891318796
Name:ANDERSON, JARED DEAN
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:DEAN
Last Name:ANDERSON
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 1:720 GLENARBOR CIR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-1743
Mailing Address - Country:US
Mailing Address - Phone:402-525-9817
Mailing Address - Fax:
Practice Address - Street 1:1710 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-5409
Practice Address - Country:US
Practice Address - Phone:308-384-4089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist