Provider Demographics
NPI:1295272433
Name:BRUCE, JARED (DO)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:BRUCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BRITTANY LN NE APT A106
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5779
Mailing Address - Country:US
Mailing Address - Phone:760-484-6469
Mailing Address - Fax:
Practice Address - Street 1:1400 BRITTANY LN NE APT A106
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-5779
Practice Address - Country:US
Practice Address - Phone:760-484-6469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP61168034208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program