Provider Demographics
NPI:1912514381
Name:DETRICK, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:DETRICK
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 1:4225 PORTSMOUTH BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2154
Mailing Address - Country:US
Mailing Address - Phone:757-292-4774
Mailing Address - Fax:757-215-2863
Practice Address - Street 1:4225 PORTSMOUTH BLVD STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2154
Practice Address - Country:US
Practice Address - Phone:757-292-4774
Practice Address - Fax:757-215-2863
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-20-137448106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician