Provider Demographics
NPI:1225563802
Name:BANKS, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BANKS
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 1:6501 YALE ST APT 806
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-4994
Mailing Address - Country:US
Mailing Address - Phone:313-662-8389
Mailing Address - Fax:
Practice Address - Street 1:6501 YALE ST APT 806
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-4994
Practice Address - Country:US
Practice Address - Phone:313-662-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703114362164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse