Provider Demographics
NPI:1992321251
Name:ANDERSON, JARED LEE (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9525 N BEACH ST STE 405
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6438
Mailing Address - Country:US
Mailing Address - Phone:817-502-7411
Mailing Address - Fax:
Practice Address - Street 1:9525 N BEACH ST STE 405
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6438
Practice Address - Country:US
Practice Address - Phone:817-502-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1144487174OtherNPPES
TX1689085193OtherNPPES