Provider Demographics
NPI:1285837815
Name:DURA, JASON RANDALL (PHD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:RANDALL
Last Name:DURA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8165 KEVIN LN
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-1097
Mailing Address - Country:US
Mailing Address - Phone:419-885-2751
Mailing Address - Fax:419-824-0455
Practice Address - Street 1:8165 KEVIN LN
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-1097
Practice Address - Country:US
Practice Address - Phone:419-885-2751
Practice Address - Fax:419-824-0455
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4078103TC0700X
MI6301010842103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical