Provider Demographics
NPI:1235541673
Name:HENRY, JASON STEWART DANIEL (MD)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:STEWART DANIEL
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-8160
Practice Address - Country:US
Practice Address - Phone:207-626-1360
Practice Address - Fax:207-626-1359
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2020-11-11
Deactivation Date:2014-12-29
Deactivation Code:
Reactivation Date:2015-01-13
Provider Licenses
StateLicense IDTaxonomies
MS928-L207R00000X
390200000X
MEMD23398207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01378761Medicaid