Provider Demographics
NPI:1295245868
Name:ANDERSON, JARED KIRKMAN (MS)
Entity type:Individual
Prefix:MR
First Name:JARED
Middle Name:KIRKMAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4033
Mailing Address - Country:US
Mailing Address - Phone:213-434-8945
Mailing Address - Fax:
Practice Address - Street 1:850 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1738
Practice Address - Country:US
Practice Address - Phone:213-807-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101688106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty