Basic Information
| Provider Information | |||||||||
| NPI: | 1629526041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LINK | ||||||||
| FirstName: | JARED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 E 3RD ST APT 605 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454025109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372570982 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4881 SUGAR MAPLE DRIVE | ||||||||
| Address2: | WPAFB MEDICAL CENTER | ||||||||
| City: | WRIGHT PATTERSON AFB | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372570982 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.