Provider Demographics
NPI:1114403318
Name:POWELL, JASON MATTHEW
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S KEELER AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-4754
Mailing Address - Country:US
Mailing Address - Phone:918-697-8588
Mailing Address - Fax:
Practice Address - Street 1:1025 S KEELER AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-4754
Practice Address - Country:US
Practice Address - Phone:918-697-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist