Provider Demographics
NPI:1235749003
Name:KING, JASON DAVID (RN)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DAVID
Last Name:KING
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-1008
Mailing Address - Country:US
Mailing Address - Phone:715-697-8140
Mailing Address - Fax:
Practice Address - Street 1:3121 3RD ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-1008
Practice Address - Country:US
Practice Address - Phone:715-697-8140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI246238-50163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice