Provider Demographics
NPI:1992250062
Name:WOODRUFF, JARED
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:WOODRUFF
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 1:14109 N 83RD AVE APT 181
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4789
Mailing Address - Country:US
Mailing Address - Phone:540-842-6074
Mailing Address - Fax:
Practice Address - Street 1:8633 W JOHN CABOT RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-0879
Practice Address - Country:US
Practice Address - Phone:623-412-4875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP 10101235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist