Provider Demographics
NPI:1518666569
Name:MARREN, JASON MICHAEL
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:MICHAEL
Last Name:MARREN
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 1:520 S RALEIGH ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2642
Mailing Address - Country:US
Mailing Address - Phone:240-527-4941
Mailing Address - Fax:
Practice Address - Street 1:520 S RALEIGH ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2642
Practice Address - Country:US
Practice Address - Phone:304-262-9831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23-911175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV23-911Medicaid