Provider Demographics
NPI:1093075855
Name:PETTY, JASON MICHAEL (HIS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:PETTY
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 VICTORY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068
Mailing Address - Country:US
Mailing Address - Phone:816-883-2660
Mailing Address - Fax:816-792-9819
Practice Address - Street 1:102 S EAST ST
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-2014
Practice Address - Country:US
Practice Address - Phone:636-456-5454
Practice Address - Fax:636-462-2702
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008009316237700000X
IL2748237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist