Provider Demographics
NPI:1063463933
Name:FORD, JASON (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 N SAINT JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2207
Mailing Address - Country:US
Mailing Address - Phone:269-687-1879
Mailing Address - Fax:269-683-0104
Practice Address - Street 1:31 N SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120
Practice Address - Country:US
Practice Address - Phone:269-687-1879
Practice Address - Fax:269-683-0104
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28165863367500000X
MI4704267914367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200539770Medicaid