Provider Demographics
NPI:1427210780
Name:COLLETT, JARED RALPH (DMD, PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:RALPH
Last Name:COLLETT
Suffix:
Gender:M
Credentials:DMD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 851 BOX 340
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09834-0004
Mailing Address - Country:US
Mailing Address - Phone:318-439-4211
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 110, 1 JUFFAIR AVENUE
Practice Address - Street 2:NAVAL SUPPORT ACTIVITY BAHRAIN
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09834
Practice Address - Country:BH
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0115351223G0001X
WAPA60034324363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1427210780Medicaid
WA0251709OtherLABOR & INDUSTRIES
WA0251709OtherLABOR & INDUSTRIES