Provider Demographics
NPI:1659169902
Name:STATEN, JARED MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:MATTHEW
Last Name:STATEN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 N 64TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2931
Mailing Address - Country:US
Mailing Address - Phone:505-814-9471
Mailing Address - Fax:
Practice Address - Street 1:590 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-288-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10091432390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program