Provider Demographics
NPI:1417228909
Name:FORT, JASON (CST/CSA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FORT
Suffix:
Gender:M
Credentials:CST/CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2778 E SUPERIOR RD
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-4573
Mailing Address - Country:US
Mailing Address - Phone:480-313-9045
Mailing Address - Fax:480-987-2186
Practice Address - Street 1:2778 E SUPERIOR RD
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-4573
Practice Address - Country:US
Practice Address - Phone:480-313-9045
Practice Address - Fax:480-987-2186
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR454110172246ZS0410X
AZL18709787246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist