Provider Demographics
NPI:1093008401
Name:HAGEN, JASON P (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:P
Last Name:HAGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 122108 DEPT 2108
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-0001
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:1000 WALTERS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4647
Practice Address - Country:US
Practice Address - Phone:337-480-8066
Practice Address - Fax:337-480-8061
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD205679207Q00000X
LA205679261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2150383Medicaid
LAMD.205679OtherSTATE LICENSE