Provider Demographics
NPI:1114454568
Name:LUSENGO, JASON
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:LUSENGO
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 1:4308 CARMEL MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-7925
Mailing Address - Country:US
Mailing Address - Phone:972-672-6612
Mailing Address - Fax:
Practice Address - Street 1:4308 CARMEL MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-7925
Practice Address - Country:US
Practice Address - Phone:972-672-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No372500000XNursing Service Related ProvidersChore Provider