Provider Demographics
NPI:1093495632
Name:SUMMERLIN, JASON THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:THOMAS
Last Name:SUMMERLIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 LANCASTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-5155
Mailing Address - Country:US
Mailing Address - Phone:503-576-8400
Mailing Address - Fax:503-364-0775
Practice Address - Street 1:255 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5155
Practice Address - Country:US
Practice Address - Phone:503-576-8400
Practice Address - Fax:503-364-0775
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA216592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine