Provider Demographics
NPI:1225452097
Name:PEREZ, JASON YAMIL I
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:YAMIL
Last Name:PEREZ
Suffix:I
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 1:142 CRESCENT STREET
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302
Mailing Address - Country:US
Mailing Address - Phone:508-941-0005
Mailing Address - Fax:508-427-6915
Practice Address - Street 1:142 CRESCENT ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3104
Practice Address - Country:US
Practice Address - Phone:508-941-0005
Practice Address - Fax:508-427-6915
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS63796894390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program