Provider Demographics
NPI:1174822951
Name:LOCKROW, JASON PARK (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PARK
Last Name:LOCKROW
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 SAND POINT WAY NE
Mailing Address - Street 2:A-5950
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3901
Mailing Address - Country:US
Mailing Address - Phone:206-987-2525
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:A-5950
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-987-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-20
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD606774892084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1174822951Medicaid