Provider Demographics
NPI:1346020724
Name:VANN, JASON DUREL
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DUREL
Last Name:VANN
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 1:8122 LEE HALL AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3444
Mailing Address - Country:US
Mailing Address - Phone:757-452-8009
Mailing Address - Fax:
Practice Address - Street 1:8122 LEE HALL AVE
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3444
Practice Address - Country:US
Practice Address - Phone:757-452-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility