Basic Information
| Provider Information | |||||||||
| NPI: | 1780162958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE BULL | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1989 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825010240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078579468 | ||||||||
| FaxNumber: | 3073330450 | ||||||||
| Practice Location | |||||||||
| Address1: | 10269 HIGHWAY 789 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825018829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078579468 | ||||||||
| FaxNumber: | 3073330450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2018 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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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 | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.