Provider Demographics
NPI:1518909357
Name:DESELMS, JASON (LP)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:DESELMS
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57950 LEAVENWORTH ST
Mailing Address - Street 2:
Mailing Address - City:MCCONNELL AFB
Mailing Address - State:KS
Mailing Address - Zip Code:67221-3505
Mailing Address - Country:US
Mailing Address - Phone:316-759-5095
Mailing Address - Fax:
Practice Address - Street 1:57950 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3505
Practice Address - Country:US
Practice Address - Phone:316-759-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1312103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS389904OtherBLUE CROSS BLUE SHIELD
KSQ64903Medicare UPIN
KS389904Medicare ID - Type Unspecified