Provider Demographics
NPI:1497995245
Name:CROCKETT, JASON ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ROBERT
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2961 MOSSROCK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5119
Mailing Address - Country:US
Mailing Address - Phone:210-731-4800
Mailing Address - Fax:210-731-4810
Practice Address - Street 1:7431 NW LOOP 410 STE 109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-3597
Practice Address - Country:US
Practice Address - Phone:210-477-7190
Practice Address - Fax:210-477-7195
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3560419-01OtherWELLMED MEDICAID
TX484297YPLSOtherWELLMED MEDICARE