Provider Demographics
NPI:1144620212
Name:FAUTHEREE, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FAUTHEREE
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 1:607 WILLOW BEND ST
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76031-0314
Mailing Address - Country:US
Mailing Address - Phone:817-312-9637
Mailing Address - Fax:
Practice Address - Street 1:607 WILLOW BEND ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76031-0314
Practice Address - Country:US
Practice Address - Phone:817-312-9637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility