Provider Demographics
NPI:1275842809
Name:PRESTON, JASON OLIVER
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:OLIVER
Last Name:PRESTON
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 1:11094 WHITHORN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-4829
Mailing Address - Country:US
Mailing Address - Phone:313-918-4794
Mailing Address - Fax:
Practice Address - Street 1:11094 WHITHORN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-4829
Practice Address - Country:US
Practice Address - Phone:313-918-4794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI272833426175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath