Provider Demographics
NPI:1114329638
Name:WHITE, JASON T (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:WHITE
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:PO BOX 22505
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2505
Mailing Address - Country:US
Mailing Address - Phone:334-279-1450
Mailing Address - Fax:334-395-4110
Practice Address - Street 1:5001 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1308
Practice Address - Country:US
Practice Address - Phone:334-279-1450
Practice Address - Fax:334-395-4110
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR881041367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered