Provider Demographics
NPI:1417265273
Name:GILBERT, JASON PAUL (RT/BS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL
Last Name:GILBERT
Suffix:
Gender:M
Credentials:RT/BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S PROCTOR ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2047
Mailing Address - Country:US
Mailing Address - Phone:253-396-5930
Mailing Address - Fax:
Practice Address - Street 1:815 S PEARL ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-2117
Practice Address - Country:US
Practice Address - Phone:253-396-5930
Practice Address - Fax:253-566-2252
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60133468322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children