Basic Information
| Provider Information | |||||||||
| NPI: | 1083195556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY-GENT | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 E MCDOWELL RD STE 206 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029561250 | ||||||||
| FaxNumber: | 6233218620 | ||||||||
| Practice Location | |||||||||
| Address1: | 13555 W MCDOWELL RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853952626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235124100 | ||||||||
| FaxNumber: | 6235124107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2018 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | DA11442 | AZ | N | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | DA11442 | AZ | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 120269 | 05 | AZ | MEDICAID |