Provider Demographics
NPI:1134763576
Name:BRABHAM, JARED
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:BRABHAM
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 1:2110 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7864
Mailing Address - Country:US
Mailing Address - Phone:337-475-0324
Mailing Address - Fax:337-475-8917
Practice Address - Street 1:2651 E NAPOLEON ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-3707
Practice Address - Country:US
Practice Address - Phone:337-625-6750
Practice Address - Fax:337-625-6752
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN158835163WP0808X
LA234094363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health