Provider Demographics
NPI:1588954200
Name:BRUCE, JARED (PHD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:
Last Name:BRUCE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 W 78TH ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-3812
Mailing Address - Country:US
Mailing Address - Phone:401-499-4043
Mailing Address - Fax:
Practice Address - Street 1:10555 MARTY ST STE 100
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-2555
Practice Address - Country:US
Practice Address - Phone:913-649-8823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1951103G00000X
MO2008007983103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist