Provider Demographics
NPI:1295357051
Name:KISSICK, JASON LEE
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:KISSICK
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 1:101 N 12TH ST UNIT 202
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4205
Mailing Address - Country:US
Mailing Address - Phone:813-363-4123
Mailing Address - Fax:
Practice Address - Street 1:3301 W GANDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2931
Practice Address - Country:US
Practice Address - Phone:813-925-1903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9350626163WE0003X
FL11007202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Single Specialty