Provider Demographics
NPI:1649985490
Name:O'MALLEY, JARED MATHEW (OWNER)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:MATHEW
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 18TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4734
Mailing Address - Country:US
Mailing Address - Phone:320-429-2307
Mailing Address - Fax:
Practice Address - Street 1:3019 18TH ST S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4734
Practice Address - Country:US
Practice Address - Phone:320-429-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1114406253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00000000OtherADULT FAMILY FOSTER CARE