Provider Demographics
NPI:1285044016
Name:MCCOY, JASON DANIEL (LMT, SLT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DANIEL
Last Name:MCCOY
Suffix:
Gender:M
Credentials:LMT, SLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 W PIONEER PKWY
Mailing Address - Street 2:SUITE D.
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-4735
Mailing Address - Country:US
Mailing Address - Phone:214-412-2079
Mailing Address - Fax:
Practice Address - Street 1:925 W PIONEER PKWY
Practice Address - Street 2:SUITE D.
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4735
Practice Address - Country:US
Practice Address - Phone:214-412-2079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT107088174400000X
TXZP10218247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other