Provider Demographics
NPI:1376100776
Name:REASOR, JASON M
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:REASOR
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:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-0856
Mailing Address - Country:US
Mailing Address - Phone:307-367-2111
Mailing Address - Fax:307-367-2166
Practice Address - Street 1:24 COUNTRY CLUB LN.
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941
Practice Address - Country:US
Practice Address - Phone:307-367-2111
Practice Address - Fax:307-367-2166
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1117101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health