Provider Demographics
NPI:1891976254
Name:PINGLETON, JARED PHILIP (PSY,D,)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:PHILIP
Last Name:PINGLETON
Suffix:
Gender:M
Credentials:PSY,D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 STATE HIGHWAY 248
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-9240
Mailing Address - Country:US
Mailing Address - Phone:417-339-4041
Mailing Address - Fax:417-336-0909
Practice Address - Street 1:2527 STATE HIGHWAY 248
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-9240
Practice Address - Country:US
Practice Address - Phone:417-339-4041
Practice Address - Fax:417-336-0909
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 103TF0000X, 106H00000X
MO01240103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA291839Medicare UPIN