Provider Demographics
NPI:1366911257
Name:PULLIAM, JARED
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:PULLIAM
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 1:812 WATTEN LN
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3777
Mailing Address - Country:US
Mailing Address - Phone:614-312-7087
Mailing Address - Fax:
Practice Address - Street 1:542 16TH ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5241
Practice Address - Country:US
Practice Address - Phone:307-324-2759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XG0600X
WYOT-1425225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology