Provider Demographics
NPI:1275991341
Name:GO, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GO
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 1:863 RIVERVIEW LN
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-1507
Mailing Address - Country:US
Mailing Address - Phone:312-622-3659
Mailing Address - Fax:
Practice Address - Street 1:1201 STONE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3563
Practice Address - Country:US
Practice Address - Phone:312-622-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI54010000157171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist