Provider Demographics
NPI:1992122303
Name:CONNOR, JARED L (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:L
Last Name:CONNOR
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 WILL HALSEY WAY STE A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2566
Mailing Address - Country:US
Mailing Address - Phone:256-325-7425
Mailing Address - Fax:
Practice Address - Street 1:708 WILL HALSEY WAY STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2566
Practice Address - Country:US
Practice Address - Phone:256-325-7425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-109689363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL206070Medicaid